GW1-2022-05986_Well Construction - GW1_20220617

SWELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: _
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. fL A-0
3 ft. . •�
NC Well Contractor Certification Number 15..OUTER CASING(full I'Vilti cased ells .OR LINER. Pa livable)
Barnette Well Drilling, Inc. FROMft TO ft. DIAMETER in THIcxNEss MATERIAL
0 6� J'a&-e1 vc
Company Name Lei�� I 0 � �tP r16. NNER CASING OR TUBING eothermalclosed-loo2.Well Construction Permit#: � ^ , O`U M TO DIA ETER THICKNESS ,MATERIAL
List all applicable well construction permits(i.e.UIC,County•State•Yariance,etc.) PL—
ft. it. in.ft ft. in.3.Well Use(check well use): SCREEN
Water Supply Well: TO DL4rIETER SLOT SIZE THICIQVESS MATERIAL
❑Agricultural ❑Municipal/Public it. in.
[]Geothermal(Heating/Cooling Supply) nResidential Water Supply(single)❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irri ation ❑Wells>100,000 GPD TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. Zp ft Cement/Sand Poured
Non-Water Supply Well: 16
❑Monitoring ❑Recovenr
ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SANDIGRAVEL PACK tfa livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To
t- �MATERLAL EMPLACEMENT METHOD
❑Stormwater Drainage ft.
❑Aquifer Test g
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal Closed Loop) ❑Tracer Z0.DRILLINOG,attach additional sheets-if necessary)
FROM TO DESCRIPTION(color,hardness,soillrock e, in size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft tJ�
( -L:t t 6
4.Date Well(s)Completed: "�Z-Well ID# ft.
TR ft. ,Z
5a.Well Location: ft ft 13 o+-y^�j 5 0 e
C!A y� 5U rt. ` �O ft. � d
Facility ID#(if applicable) ft. ft.
Facility/OwnerNa/me ,, ty pp
L-.�/O e � 4�../� � ft. ft.
/ C� 1 1 w>= /7�J ft. ft a
Physical Address,City,and Zip
31.REMARKS
County Parcel Identification No.(PIN) ! �rc�c�--�--v,e
41
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �:;rmrr t,I UN YI%ULA:bJ h�i'
(if well field,one ladlong is sufficient) 22.Certification:
36 o i5"7 12 N C? 7 (9 o W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): nf-ermanent or ❑Temporary
By signing this form,!hereby certify that the we11(s)was(were)constructed in accordance with
7.Is this a repair,to an existing well: ❑Yes or MN1 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out(mown 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:
S.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: . (It-) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dderent(example-3Qa 200'and 2@1001
'Z.S� 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
Ifwater level is above casing,use"+"
/ 24b.For Infection Wells:Copy to DWR,Underground Injection Control(lUC)
11.Borehole diameter: fo (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Rota 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield Win) 20 Method of test: f
I -.Disinfection type: HTH Amount: p
Form OW-1
North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018