GW1-2022-01276_Well Construction - GW1_20220112

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ro fil I A ILE tk FROM TO DESCRIPTION
Well Contractor Name It-
20
3Z 2 ft- ft- _q
NC Well Contractor Certification Number 15.-OUTER CASING(for'mzilti�4�sdd"PV611i) R,M- ER(ifdbjiIicibI0 'T
Barnette Well Drilling, Inc. PROM TO DIAMETER THICKNESS MATERIALin.
Company Name ^ 16.'TNNE]k,CASING,0R TUBING W(gee"60her' 'fc1osid-IooiA:--
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS MATERIAL
6
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) It. ft in.
ft. ft. in.
3.Well Use(check well use):
IT.SCREEN.. Z.,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS IMATERIAL
ClAgricultural OMunicipal/Public ft. tt. in i•
_+
DGeothermal(Heating/Cooling Supply) (IResidential Water Supply(single) ft. ft. in.
01ndustrial/Commercial OResidential Water Supply(shared)
1 481-GROUT!
11 Irrigation DWells>100,000 GPD FROM I TO MATERIAL -EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft, ft GowRWRysfTd Poured
DMonitoring CIRecovery ft.
Injection Well: ft. ft
•Aquifer Recharge OGroundwater Rernediation 1.9—
.SAN06RAVEL PACK ffa0pIiea6leY,.,-,
•Aquifer Storage and Recovery 0 Salinity Barrier FROM I TO MATERIAL I EMPLACEMENT METHOD
•Aquifer Test OStormwater Drainage ft. ft.
•Experimental Technology 0 Subsidence Control ft. ft.
OGeothermal(Closed Loop) CTracer 20j:pRJLLING'LQG(attach,additional,sheitvif necessary)
0 Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks)— FROM ft. TO ft DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
n 4.
4.Date Well(s)Completed: J Well ID# 4�3 ft
5a.Well Location: to it 15 C_
&—/I-a t 1,a 2,5-ft' I 2,06"L
Facility/Owner Name Facility ID#(if applicable) ft• ft
ft ft
7 4�X-e
ft
Physic ddress,City,and Zip
r.21.REMARKS' 4 �i 4
r_fr)&6A--
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient)
22.Certification:
N W
Signature Of Certified Well Contractor J' Date
6.Is(are)the well(s): tHwerinanent or OTemporary
By signing this form,1hereby certify that the well(s)was(were)constructed in accordance with
15A NCAC 02C.0100 or 15A NCAC 0 1 2C.0200 Well Construction Standards and that a copy
7.Is this a repair to an existing well: OYes or 1LW I
Ifthis is a repair,fill out known well construction information and explain the nature of the ofthis 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: (fo Submit this GW-1 within 30 days 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: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
24b.For Injection Wells: CopyP DWR,Underground Injection Control(IUC)
11.Borehole diameter: eS (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Rotary I
24c.For Water Supply and Open-Loop Geothermal Return Copy to the
(i.e.angel,rotary,cable,direct.push,etc.) county environmental health I department of the county where installed
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producin I a over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) '70 Method of test: 64040 Permit Program, 1611 MSC,Raleigh,NC 2 1699-1
611
4J_-knlr-�' I
13b.Disinfection type: HTH Amount: TqX��
Form C.W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018