GW1-2022-05985_Well Construction - GW1_20220617

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14_WATER ZONES I
We11VCo�n~traLctorName FROM TO DESCRIPTION
ft-
ft. ft -Z1`
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased ells)OR LINER(if a livable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. / m. �Ot .2!
Company Name d`e ft t6 /A f
Ili.INNER GASING,OR;TUBING eothermal closed-loop)_
2.Well Construction Permit#: (� Z 2 "- O G'1'cA FROM zo DIAMETER zHIClavEss MATERIAI
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft. ft. �•
Water Supply Well: 17.SCREEN.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) [']Residential 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: ft ft Poured
❑Monitoring ❑Recovery ft 315 ft (�
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND(GRAVEL PACK rf a livable
El Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACFAN ENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. fL
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20 DRILLING'LOG attach additional sbeets if necessi
typ❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(co/l�or,hardness,soil/rocke, in size,eta)"
4.Date Well(s)Completed: �-2- Well ID# L 2 ft. l� ft 2 ` 1,aJ
5a.Well Location: :ft. 3�- ft k& i
C/O�iF :�r�n 3 T!�/1/l 3,4—ft. ft
Facciilyity/(Ow der Name �, n Facility ID#(if applicable) t0r ft. G ft.
Physical Address,City,and Zip ft ft. 7-
Q R-A Aff `e �i 6/ 6 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification: C)l PR fE°•^J'dl . H
-
.3 6 N
6.Is(are)the well(s): LifPermanent or []TemporarySignature o Certified Well Contractor~ Dace
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to.an existing well: ❑Yes or 0 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis 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.
iepair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details
8.Fo'r 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-Lis 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 dierent(example-3@200'and 2@100)
24a. For All Wells: Original form to.Division of Water Resources (DWR),
If Static water level below top of casing: �5 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ijwater 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
(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
�d
13b.Disinfection type: HTH Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018