GW1-2022-01273_Well Construction - GW1_20220112

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Well Contractor Name FROM TO ft. DESCRIPTION
/& I,- f.?-Z> 3 Lm/ I
4-o ft- i y,5- -1 ag.4
NC Well Contractor Certification Number
15.OUTER`CASIN(,'.(f6r.diiilti!asid r 2io icablo. -z
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
C
in.
Company Name
16ANNEWCASING'OWT.
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
io fL in.
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. I
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ON[unicipal/Public ft. ft. in I. I
OGeothermal(Heating/Cooling Supply) IlResidential Water Supply(single) ft ft. in.
01ndustrial/Commercial OResidential Water Supply(shared) 18.-GROUT
DIrrigation OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft CQwA4V-Saad Poured
13Monitoring ORecovery ft. 2-C, ft. dew
Injection Well: ft.
OAquifer Recharge OGroundwater Remediation
'19.,SAND/G!tA,VEL PACK:(tf,apoliL
•Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
•Aquifer Test C1 Stormwater Drainage ft. ft.
DExperimental Technology OSubsidence Control ft ft.
DGeothermal(Closed Loop) OTracer
DGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM ft TO -ft DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
4.Date Well(s)Completed: -7-2-( Well ID# 2-J4-
IL 4S­ ft �'01eGA1 1+12
5a.Well Location: 1,5ft. 1&6 ft e,�;RA K
9U Ob do ye- ft. ft.
Facility/Owner f4ame Facility rD#(if applicable) ft. ft.
4- 0", %6
Physical Address,City,and Zip ft. ft.
Cp -.7
County Parcel Identification No.(PIN) JAN 12 ?.07 1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36. Sob 1-9 N 7 5 0 7 -2-5-0 W
6.Is(are)the well(s): Cgkl-m-anent or oTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or &NiT- 15A NCAC 02C.0100 or 15A JVCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-I within 30 day i s of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2@100')
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,161 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter: (in.) 24b.For Injection Wells: Copy to DWI(,Underground Injection Control(rUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Rotary
n',etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct.push
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DVV`R,CCPCUA
111 Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 4e-5- Method of test:
13b.Disinfection type: HTH Amount: 112 Cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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