GW1-2022-05965_Well Construction - GW1_20220615

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
�yV � U_0 T-r 14:WATER ZONES
FROM TO DESCRIPTION
-A
Well Contractor Name
ft. l Kz ft. tr
�r- 1�6 it. _T_r/_a*r
NC Well Contractor Certification Number 15.OUTER CASING(for niulti4ased wells)OR LINER(if '.
a .livable)
Barnette Well Drilling, Inc. FROM To DIAMETER THICI=SS MATERIAL
ft. t. in.
Company Name V
16.INNER:GASING OR:TUBING eothermal closed-loo
2.Well Construction Permit# 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) L•JResidential 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: A
ft. o 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 ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20r,DRILLING.LOG attach•additional:sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESC
RIPTION(color,hardness,soil/rock type,grain size,etc.)
4.Date Well(s)Completed: T 26`-,�_Well ID# /i / 3 it. gr %
5a Well Location: ( 6 ft• 5-j ft Ae-+
Facility/O t.
ner Name Facility ID#(if applicable) ft. f
/ty S �/ �fSf� l P/� Lea ft ft.
Physical Address,City,and Zip ft. ft.
#et2�t] , r `21.REbIARKS
.County /� Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification: IL i a P R:) _:f,.i,�:G JN,
�C c ,�1,9 S,-f.) N 73"- �Q ��4.' C_�
6.Is(are)the well(s)• L4Pe't'fnanent 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 MPlo- ISA 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 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: ez'�� (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
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
(Le.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
14 Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) /0 Method of test:13b.Disinfection type: HTH Amount:1 `Q
` ce ?—
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018