GW1-2022-04103_Well Construction - GW1_20220418

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: j
1.Well Contractor Information:
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14.WATER ZONES
Well
lContractor Name
(� g FROM---_ TO DESCRIPTION
�Y`�' � G- � ` � 2�Grt z �f t r '
rt rt S A 3o f 83SF+� AJ
NC Well Contractor Certification Number
Inc. 15.OUT.ER CASING(for id,wells OR LINER(if a liable)
Barnette Well Drilling, nc FROM TD DIAMETER TBICKNESS MATERIAL
Company Name ft ft
16ANNER.CASING OR TUBING-tee6therrnal closed I66
2.Well Construction Permit#: FROM TO I DIAMETER 11 TFFI--- LESS MATERIAL
Lust all applicable well construction permits(i.e.UI ,County•State, Parlance,etc.) ft ft. in. Jf
26 t
3.Well Use(check well use): ft• ft in. tJ
Water Supply Well: 17.'SCREEN
FROM TO DIAMETER I SLOT SIZE I TMrTc ESS I MATERIAL
❑Agricultural ❑MunicipaVPublic ft ft is
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft ft
❑Industrial/Commercial ❑Residential Water Supply(Shared)
18.`GROUT
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft Cement/Sand Poured
❑Monitoring ❑Recovery ft. ft
Injection Well:
❑A uifer Recharge ft• ft
4 ergs ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salim Barrier 19.SAND/GRAVEL PACK tf a ]icable'.
ty FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 10.DRILLING.LOG attach additionil,sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROMI TO DESCRIPTION(color,hardness,soiuroek type,grain sim•etc.)
AL),a .360
4.Date Well(s)Completed: 6-Z<�: Well ID# ft. ft
5a.Well Location: ft. ft
y ` ft ft
Facility/Owner Name Facility ID#(if applicable) ft ft `�;�Rp tm g
D61 Z- _ ft. ft -
Physical
Address,City,and Zip ft t
Crj` fSea zt Z 21.REMARKS
County Parcel Identification No.(PIN) '!`Q"iS a•"F^^. 1 r 't( :;ij
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/lorig is sufficient) 22.Ce don: 7
N W ��/ Z
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Welt Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: MNo 15A NCAC 02C.0100 or ISA NCAC 01C.0200 Well Construction Standards and that a copy
If this is a repa r 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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary,
drilled:
�D
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
For multiple wells list all depths iifdijjerenr(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: t5� (ft) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
/fwater level is above casing,use"+^ Information Processing Unit,1617IMSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Air Rotary
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: '7 24c.For Water Supply and Open-Loop Geothermal Return Was:Co to the
(i.e.auger,rotary,cable,directpush etc.) county environmental health department of the county where installed Copy
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Producinedover 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) /1' Method of test: Permit Program,16111 Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018