GW1-2022-01284_Well Construction - GW1_20220112

WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
1.Well Contractor Information:
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14.WATER ZONES i
Well Contractor Name FROM TO DESCRIPTION
5� 76' — - / 9rft. ;—, Zroft g
NC Well Contractor Certification Number 2
:15.�OUTER-CASING for m6lh cased well`s OR LINER if a 'livable
Barnette Well Drilling, Inc. FROM To DIe4r1ETER THICKNEss MATERIAL.
��11 ft Z ft. f in. , �t
Company Name V I V e
L� 16rINNMCASING:UR`TUBING eotherinal closed-'loo
2.Well Construction Permit#: 7 FROM I TO I DIAMETER I TRICKNESS MATERIAL
List all applicable well construction permits r.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 DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. it. in.'
❑Geothermal(Heating/Cooling Supply) MIZesi—dential Water Supply(single) ft.
❑IndustriaUCommercial ❑Residential Water Supply(shared) 48:GROUT
❑hri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: tt cP
v ft- Cement/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
14:SAN
❑Aquifer Storage and Recovery ❑Salinity Barrier FROrM D/GRAVEL-PACK tfaticabie TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothemtal(Closed Loop) ❑Tracer 20c'DRELLING LOG(attach additional sheets if necessary).
❑Geothermal FROM TO DESCRIPTION(color,hardness,soillrock e, in size,etc.)
(Heating/Cooling Return) ❑Other(explain under#21 Remarks) fa ft LL ��
d U t2 PG
4.Date Well(s)Completed: a—i r Well ID# A 3 ft ". e \ t,
5a.Well Location: ft. ��n J� t� jL f'j..41e
6'Py11rf e-p 117n S"' 115-3 ft' / ' .X� qLJDAcIQ—
Facility/Owner Name /jam t , /� Facility ID#(if applicable) S 1 QD I tee'4 a7
Zt7 2 9 Act�1i9!1/ylc�ay y 1h ft ft. O Y� I
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Physical ddress,City,and Zip ft. ft.
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County Parcel Identification No.(PIN) 1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: A
(if well field,one lat/long is sufficient)
�7j r 22.Certification: 1F.1'�, ^^r T.`
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6 -3I tre T N `2 r SV 4-t� 6 W —g
i;: ,'•r� ^;r.,' ]/,�,lj
6.Is(are)the well(s): Q$ertf vent or ❑Temporary Signa ure of Certified Well Contractor Date 2
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 ®N011 15A NCAC 01C.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 oj'this record has been provided to the well owner.
repair under#21 remarks section or on the back of thisform.
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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ft
For multiple wells list all depths if different(example-3Q200'and 2@1001 ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: Z+Sr (ft.) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
If water level is above casing,use"+- Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in,) 24b.For Injection Wells:Copy fo DWR Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
.Well construction method:Air Rotary
24c.For Water Supply and Open Loop Geothermal Return Wells:Copy to the
(i e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For-Water WpIls.producing over 100,000 GPD: Copy to DWI,CCPCUA
Permit Program, 1611 MSC,Raleigh;NC 27699-1611
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13a.Yield(gpm) L Method of test: la r� f
13b.Disinfection type: HTH Amount: ta CUp r
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 A