GW1-2022-05974_Well Construction - GW1_20220617

WEF.Y.CONSTRUCTION RECORD(GW-Y) For Internal Use Only:
1.Well Contractor Information:
'n-1 4f i. - (/Q K u-'� 14.WATER ZONES
Well Contractor Name FROM, TO DESCRIPTION
ft ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER(it ap likable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name & it G---ft 6 l in. rA 1 _I*C
16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: 2, S, 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) InResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hTi ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&ZROUNT
Non-Water Supply Well: 6 ft- 3Z f° Cement/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barer 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 necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock e, in size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Z
ft. 3 fL d v(tJ
4.Date Well(s)Completed:
C!` 0"Z�We1lID# 7( �.� ft.
5a.Well Location: /e Z ft. �a ft. 9
ft. l ft (5910 fly Q A (�
Facility/Owner Name /i >JFacility ID#(if applicable) jy'a ft. en' ft.
'
6 7 -A-A C j �(\ __ _A �( 1� ft ft
ft. ft.
Physical Address,City,and Zip
21.REMARKS �"'+rfi`°'` rt^y n
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: JU ' 1
(ifwell field,one lat/long is sufficient) ' P 22.Certification-
6.Is(are)the well(s):T eP rm ent or ❑Temporary Signature of Certified W-ell Contractor Date
By signing thisform,I hereby certifv that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ANo- 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 infonnation 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 I 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.)
For multiple wells list all depths if dierent(example-3@200'and 2@1000 Submit this GW-1 within 30 days of well Completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: z (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"++"°
11.Borehole diameter: 016 (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
(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.Y ield(gpm) Method f test: �00-44 Permit Program,1611 MSC,Raleigh,NC 27699-1611
�/� o
13b.Disinfection type: HTH Amount: V -JIt -2-
Form GW-I North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 6-6-2018