GW1-2022-01280_Well Construction - GW1_20220112

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: [
�42(n f -14:WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
D ft. 10ft D I C A/.5— JJ/rt Jf_ y a qV
_?.? 7 tS A ft. ft.
NC Well Contractor Certification Number
Ia.OUTER CASING'for,multi-casedd'wells)•OR'I;INER.if'a� livable
Barnette Well Drilling Inc. O R THICIG�IESS MATERIAL
� ft. Z ft
Company Name 16rINNER:CASING OR>TUBING e _
FROM TO
Q other' dI&bwd-loo
2.Well Construction Permit#: CJ FROM TO DIAMETER THICIGVESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft fL in.
Water Supply Well: 17.SCREEN
FROM TO DMWETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. it. in.
❑Geothermal(Heating/Cooling Supply) lKe--sidential Water Supply(single) ft. ft. in•
❑Industrial/Commercial ❑Residential Water Supply(shared) :,18.GROUT .-
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. tt Gement/Smd Poured
❑Monitoring ❑Recovery ft. ft. �t
Injection Well:
ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL PACK ifa livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
[]Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer :20 DRIL LING.LOG f attach additionaCsheets ifneces'sa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM ft ft TO DESCRIPTION(color,hardness,soil rock type,grain size,etc.)
1�
4.Date Wells)Completed: 10-1 Y"ZI Well ID# )�O ft. 2 ft 1 ��
5a.Well Location: ft. 6Oft
re-gIQ V W ft. ft
Facility/Owner Nome Facility ID#(if applicable) ft. ft.
/V 2 fC if 6 1`lr� Z4 0 2 i�I C 2� �0- ft. ft.
Physical Address,City,and Zip
21:iRE14IARKS.r� ;'.: ,�•...:_
OrCA.S z `� �
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: f Z?
(if well field,one tat/long is sufficient) 22.Certification'
N '7 V egf94'0 W dfA&7�
6.Is(are)the well(s)' )frmanent or ❑Temporary 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: ❑Yes or A?fo 15A NCAC 02C.0100 or 15A NCAC 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 9 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3@200'and 2@I00D
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
lfwater level is above casing,use"+"
11.Borehole diameter: G (in.) 24b.For Injection Wells: Copy;to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Ai r Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push etc.) 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 DWR,CCPCUA
*� r Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) / © Method of test: BW
13b.Disinfection type: HTH Amount: " '"P" " 9 ,0 °
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource s Revised 6-6-2018