GW1-2022-05799_Well Construction - GW1_20220615

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Informaation:
1 e 1�� I! �/�°/f(i (/G l g 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
Z �l 4 / rs ft. I?e) ft. S
160 ft. It.
NC Well Contractor Certification Number 15.OUTER CA for multi-cased wells OR LINER:(if a licable)'
Barnette Well Drilling, Inc. FROM % DIAMETER THICKNESS MATERIAL
Q ft. I
/(Z-ft in. g p vG
Company Name
3 y 16.INNER CASING OR TUBING geotberinal closed-loop)
2.Well Construction Permit#: (� J G- FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits C.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ,
ft. ft. in.
Water Supply Well: 17..SCREEN
FROM TO ILAMETER SLOT SIZE THICKNESS MATERIAL
OAgricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) f"Residential 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: 2 t C an
❑Monitoring ❑Recovery b ft. .Zb It'
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
[]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 20.DRILLING LOG attaci additional,sheets.if aecessa
FROM TO DESCRIPTION(color,hardness,soUtrock type,grain size,etc.)•'
❑Geothermal(Heating/Coohng Retum) ❑Other(explain under#21 Remarks) ft 7-0 ft.
4.Date Well(s)Completed: I 2 Z Well ID# �✓ Z Z Q ft. O ft.
5a.Well Lo�c/ation: - ft. tic ft.
s tell GT V,/l� (9 h j ft. ft
Facility/Owner Name n Facility ID#(if applicable) ft. ft.
pOCO N o k"' `fj' ft. ft.
Physical Address,City,and Zip ft. ft.
FT1/1& /tl t0" I$�y-(,g' 2-7 /1 21.REMARKS y
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Cri`.•'; s;x :i't'i a �i
(ifweli field,one lat/long is sufficient) 22.Certific 'on' li"i ;'i iN,i il:r�Pf OI,,!G'�'i13 JIMT
'10 yr I lr 2 Y N �L'ysl d W2?
6.Is(are)the well(s): f�isermanent or ❑Temporary ?gna Me of Ce ified 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 / INo 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 ojthis record has been provided to the well owner.
repair under#21 remarks section or on the back ojthis 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.) 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)
224a. 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
If water level is above casing,use
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,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
/0 Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) �0 Method of test: 1
13b.Disinfection type: HTH Amount: 1/2 Cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018