GW1-2022-05789_Well Construction - GW1_20220615

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
N La e L e P� L.L 6 14:_WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3 Z - G ?oft. i a G ft t� �s
NC Well Contractor Certification Number 15..OUTER CASING(for multi cased wells)OR LINER if a' livable)
Barnette Well Drilling, Inc. FROM TO THICKNESS MATERLU
ft. ft. DIAMETER in.
Company Name
I6.INNER;CASING OR TUBING m eotheral closed-loo rr: -
2.Well Construction Permit#: LlO Z ® / FROM TO DUMETER THICKNESS MATERIAI
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) dA ft. ft. J� in. :5-C 4LQ v
3.Well Use(check well use): V ft. fL in.
Water Supply Well: 17.SCREEN. .
FROM TO DL METER SLOT SIZE TffiCKNESS MATE
❑Agricultural ❑Municipal/Public ft. ft. in,
❑Geothermal(Heating/Cooling Supply) &R idential Water Supply(single) ft. ft. in,
❑Industrial/Commercial ❑Residential Water Supply(shared) -'18 GROUT-
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERLIL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft- 16 fL -Cement/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL'PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERLIL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. fL
❑Geothermal(Closed hoop) ❑Tracer c20i'DRILLIN,.G;L-OG. attach additional sheets if necessary),
FROM TO DESCRIPTION(color,hardness,soil/rock e, in sue,etc.)
❑Geothermal(Heating(Cooling Return) ❑Other(explain under#21 Remarks) /�dt 1�6 at• g
4.Date Well(s)Completed: /6-2 Z Well ID# w Z 2 -Q ft. ft.
ft. fL
5a.Well Location:
,f2e/Ztt3ld� ft. ft.
Facility/Owner Name Facility(IDS#(if applicable) ft. ft.
ft. ft. �•,,a"�.�--�.r"T
Physical Address,City,and Zip ft et.
JUN
21.REMARKS
377K7�b
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees
(if well field,one lat(long is sufficient) 22.Certification:
3 N 4-7Ld763 W C-
dl�
& -
6.Is(are)the well(s): L$Pel manent 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: es or ONo 15A NCAC 02C.0100 or]SA 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 TQQ,, L TANUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
Cl drilled: 6-"A" d�>e��e2 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: r 90 `,Zv c-, (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)
10.Static water level below top of casing: P%5 (ft.) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is 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,directpush,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
©���r Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) L� Method of test: G°\
13b.Disinfection type: HTH Amount 6 6; Jp
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018