GW1-2022-05802_Well Construction - GW1_20220615

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name �-� FROM TO DESCRIPTION
I go ft- 1?0 ft 20 01 Z Idd
NC Well Contractor Certification Number 15."OUTER CASING for multi-case ;OR LINER if a livable)
Barnette Well Drilling, Inc. FROM TO DIAMMETER THICKNESS MATERIAL
ft. 4-6 ft-
t G in. L
Company Name
^� pp�� ,16.INNER.CASING.UR<T.UBING eothermal closed-loo
2.Well Construction Permit#: 3 3 ! t V p FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.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 DIAMETER SLOT SIZE THICKNESS MATERIAL
[]Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Afre'sidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) =18;,GROU.T
❑Irrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft- 7.0 ft- 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 El 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 attach additional;sheets.if necessa
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiltrock t3rpe in size,etc.)
O ft. t" fL 0 fe e 2
4.Date Well(s)Completed: J�- ZLWell ID# 3 �� l3 6_ it- J Z ft' tA
5a.Well Location: 1 2- ft. 2. Q ft. �
Facility/Owner Name Facility M#(if applicable) ft. 3�D ft. ke C�G
6016- ON k nab 0P_a ft. ft. f
Physical Address,City,and Zip �j ft. ft-
AM jq e�fqm I C-7.r G � 21.REMARKR . ` :.
County /T Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ^O'" �f '.1"''r`_� '"?
(ifwell field,one lat/long is sufficient) 22.Certification-
g3 r. - N -) -P- '?0 ?2-?__W R,,,
6.Is(are)the well(s): MINermanent 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 Lit t6 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: �y (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(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
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
(i.e.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) Method of test Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: P 167
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018