GW1-2022-04107_Well Construction - GW1_20220418

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: ) , -
t :14 WATER ZONES 1. .
Well Contractor Name FROM TO DESCRIPTION
ft. ft
NC Well Contractor Certification Number 15'OU TVA CASING for,mutti�s'sed tivells OYt LINER;rf a' ricabie
Barnette Well Drilling, Inc. FROM TO DIAMETER TRIC'NESS MATERIAL '
ft. I ft.
Company Name
16:INNER CASING-'OR TUBIKG'"eothermal closed=.Ioo , r z.
2.Well Construction Permit#: FROM TO I DIAMETER I TRICKINESS MATERIAL
List all applicable well construction permits r.e.UI ,County,State,Variance,etc.) ft. ft in. I
X 26
U
3.Well Use(check well use): ft ft in.
17.SCREEN
Water Supply Well: .:'
FROM TO DIAMETER SLOT SIZE TMCIINESS MATERIAL
❑Agricultural ❑Municipal/Public fL ft. in.
❑Geothermal(Heating/Cooling Supply) [!]Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18•:GIiOUT.
[]Irrigation ❑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:
rt. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACKr tf,o"livable � , `.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage IL ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG.a ttich,addiiionaLsheets if neces'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,saiUrock e, in size etc
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4.Date Well(s)Completed: 6r Z Well iD# ft. ft
ft. ft.
5a.�Well Location: ft
Facility/Owner Name Facility ID#(if applicable) ft ft.
�0612- 5c.Ah � ft ft
:,_, r~:
Physical Address,City,and Zip ft ft y F'?�1 Add«"
-21.REMARKS;
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one laVlong is sufficient) 22.Ce lion' L� "'I",1rvN i i �)�A"J.vl+'G IUN
N w ,� ���' 1G zz
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified well Contractor Date
, By signing this form,!hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: LCY'Es or� ONo 15A NCAC 01C.0100 or 1 SA NCAC 02C.0100 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
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9.Total well depth below land surface: J 4D (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3®206'and 2@100)
10.Static water level below top of casing: Z (f�) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
1f waxer level is above casing,use Information Processing Unit,1617I MSC,Raleigh,NC 27699-1617
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) 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
(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 yroducint over 100,000 GPD: Copy to DWR CCPCUA
tip Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: HTH Amount
V
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018