GW1-2022-05788_Well Construction - GW1_20220615

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.WQII Contractor Information:
14.WATER ZONES
Welj Contractor Name l ► FROM TO DESCRIPTION
ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER(if a 1'icable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS I MATERIAL
ft. ft
Company Name in. s �Q 1 )�
16.,INNER,CASING.OR.T.UBIYCn(aeothermal•closed-loo )
2.Well Construction Permit#: FROM TO EIMMETER THICKNESS MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: FROMREE TO DL41IETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) nfresidential Water Supply(single) ft. ft. in.
❑hidustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. GemeWSaii4 Poured
❑Monitoring ❑Recovery ft 6 ft. b ��
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK-(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEME`1T METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology [--]Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20;DRILLING LOG attach additional sheets ifnecessaryl
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
c ft. ft. It (`- Z L za t�
4.Date Well(s)Completed: 2'Z3 2�Well ID#�U)Z 1 --tOtL q ft. ft.
5a.Well Location: ft. -3 ft.
Lb }
J ft.
�Z 6 P
Facility/Owner Name p Facility ID#(if applicable) it. ft. F 7— ,h At "t,a
ft. it �'"a.S""� r��T,p `?�'i;_...
Physical Address,City and Zip it. ft. I 1
21.REMARKS
County Parcel Identification No.(PIN) q�1 r ��,,,
,J pp,0 3vS c J IN
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat(long is sufficient) 22.Certification:
6.IS(are)the Well(s)' rmanent 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 SN-0 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: /A (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@100)
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
Ifwater level is above casing,use"+"
11.Borehole diameter: (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
1�
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 producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm)
��U-J Permit Program,1611 MSC,Raleigh,NC 27699-1611
�. � Method of test: 11
13b.Disinfection type: HTH Amount: Cu
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018