GW1-2022-05964_Well Construction - GW1_20220615

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1. / j6Well Contractor Information:
(R 4l f lV i e_ ,�� &LL� 14.WATER ZONES
Well
Contractor Name FROM TO DESCRIPTION
3 ft.f
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a livable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
rt. 11 ft /f in. �° ` 2ell
e
Company Name 0 U
16.INNER CASING UR>TUBING.. eotbermal,closed-loo -
2.Well Construction Permit 77 FROM TO DIAMETER I 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: IT.BCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
[]Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) nResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) Y18.GROUT
❑irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: ft. ft- 1_idll4 Poured
❑Monitoring ❑Recovery �, ft. _ ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
.19.SAND/GRAVEL PACK if applicable)-.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMYNT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20:-DRILLIIYG LOG attach additional.sbeetsif.necessar
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilfrock a rain size,etc.)
ft. � ft. � 1 �
4.Date Well(s)Completed:
5a.We Location: /� is-ft. ��ft. 7 e.^
/1 L9 3 ft. X3-ft S r7
Faci6,;0wVner Name 9 Facility ID#(if applicable) �S-1t. / ft. ,n
ft. ft
Physical Address,City,and
gZip
, y �[ [' ft rt. P 11" P
?1 (���-T'� 21.RET'IARKS y A o_
County Parcel Identification No.(PIN) 9
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat(lon is sufficient +'�'•"9w d',l
C g ) 22.Certification:
9
3fa TO� Z N "/ ✓ t3 0/ W _ A a i'ti�'✓ illdJtl
�ry
6.Is(are)the well(s): nllz�rmanent or ❑Temporary Signature of Certified Well Contractor Date
_ / By signing this form,I hereb"v certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or �00 15A NCAC 02C.0100 or ISA 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: ® (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@100D
7 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••+"
11.Borehole diameter (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
p
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
/j Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) �l� Method of test:��L1t!r/rt°i'`-��t c
13b.Disinfection type: H T H Amount: /'` ?t$�
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018