GW1-2022-01285_Well Construction - GW1_20220112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
•�-e+�+/"'/2117a C,k- LIQ-L -14.WATER.ZONES .^
FROM TO c DESCRIPTION
Well Contractor Name
,?,) .7 6 � LD ft. � .1t f � f'►
rt. iLr.
NC Well Contractor Certification Number
15.OUTER EASING rot•multi=cased:wetis)ORL'INER,ita "licsble)"•-`:.. •. �:::.
Barnette Well Drilling, Inc. FROM TO DUMETER TEnCIGNESS MATERIAL
rt. Z ft. � in. f'ixK-� //�
Company Name v
..16�'INNER CASING OR:TUBTNG; aothermitefosed-l"oo' ,--., ".•v ;:-;
2.Well Construction Permit#: ei
FROM To DIAMETER THICKNESS 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.
Y1.SCREEN '' T. .,
Water Supply Well: FROM TO DIAMETER %SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) dReidential 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: U ft- .Za IL Ceme"Rwt Poured
❑Monitoring ❑Recovery ft ft leN
Injection Well:
(t. ft.
❑Aquifer Recharge ❑Groundwater Remediation
.19s•SAND/GRAVELPACK tf:a lic'bii
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
[]Aquifer Test ❑Stormwater Drainage ft. fL
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 29.'DRILLING'LOG attach,idditionil sbeetstifnecessi F
FROM TO DESCRIPTION(color,hardness,soil/rack type,gain size etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) ft. ft
4.Date Well(s)Completed: ��� P Z JWell ID# ' ft. 2- 5 it. �� C
5a.Well Location: Z� ft. ft /f,U �� Z
e lA�z IvAt�? Ad r✓1eS i .d rt. co ft
Faciliitty///Own Name j J Facility ID#(if applicable) ft. ft.
&?(II ICJ� ���: ft. ft.
Physical Address,City,and Z-p ft tt 1 F�
A _
� d C 7 ..21.`REr4ARKs'. a
�' -
County Parcel Identification No.(PIN) iAN k 2 7G/'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification 'U' -
6.Is(are)the well(s): LRPermanent 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 1!5 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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
For multiple wells list all depths ifdifferent(example-3@200'and 2@1001 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (f>) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
!f water level above casing,use +
11.Borehole diameter: (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
/�
Program, 1636 MSC,Raleigh,NC 27699-1636
12.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 Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
/� 4:5 Permit Program,1611 MSC,Raleigh,NC 27699-1611
H
13a.Yield(gpm) /'C� Method of test: B
13b.Disinfection type: Tu Amount: 1/2 Cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018