GW1-2022-05962_Well Construction - GW1_20220615

WELL CONSTRUCTION RECORD(GW 1)
For Internal Use Only: ,
1.Well
lContractor Information:
14.WATER ZONES
Well Contractor Name. FROM TO DESCRIPTION
7 6 r� 3 �dit. y t. ��. A
rt. %�y rt
NC Well Contractor Certification Number O•
15F- F
OUTER Cr multi. sed wells.OR LINER if a ' lieable)
Barnette Well Drilling, Inc. DIAMETER THICKNESS MATERIAL
Company Name in.Oo TUBING eothermal✓closed-loo 2.Well Construction Permit#: 7DIAMETER THICKNESS MATERIAL,List all applicable well construction permits i.e. IC,County,State,Variance•etc) in.
3.Well Use(check well use): in.
Water Supply Well: 17.SCREEN
❑A Cllltural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Municipal/Public IL ft. in.
❑Geothermal(Heating/Cooling Supply) dResidential Water Supply(single)
❑Industr-ial/Commercial ❑ It. IL in.
Residential Water Supply(shared)
18.GROUT
❑Irrigation ❑Wells>100 000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ® ft. 2,gD IL Cement/Sand Poured
❑Monitoring ❑Recovery ft ft.
Injection Well:
❑A uifer Recharge Groundwater Remediation ft. ft.
❑Aquifer Storage and Recovery ❑Salim Barrier 19.SAND/GRAVEL PACK: if applicable)
ty FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft. It.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additionalsheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM ft ft To DESCRIPTION(color,hardness,soiurock e, rain sue.etc.)
o � ��
4.Date We
Completed: +-2S'a2 Well ID# �S J� ft. ft
Sa.Well Location: ft
• 3
Vie-/6 e A7.- 3-f ft' -S6 IL
Facility/Owner Name /Facility ID#(if applicable)
-QIt• � � e, "rofft. 1�C �Y �
Physical Address,City,and Zip ft fL ,-
��J Q 5 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: v v
(ifwelllf field,
�one]at/long is sufficient) 22.Certification:
9� ���� J�� -�PIZ
6.Is(are)the well(s): [11 ermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this for ni,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or X?ro- 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 ofthis 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: �C-) ft
For multiple wells list all depths if different(example-3@200'and 2@100D ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: ZS ft 24a. For All Wells: Original form to.Division of Water Resources (DWR),
!'water level is above casing,use"+- - (ft-) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells•Copy to the
coon en 1 heal department o e county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells yroducine over 100,000 GPD• Copy to DWR,CCPCUA
13a.Yield(gpm) 2. Method of test: l Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: M ,e,_
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources R evisert r-r-9n 12