GW1-2022-05998_Well Construction - GW1_20220617

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only-
1.Well Contractor Information: _
R, 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
oft. , ft. 6q.
NC Well Contractor Certification Number '15-OUTER CASING for,mtilti,cased wells)OR LINER(if a livable)
Barnette Well Drilling, Inc. FROM TO DIAMETER HI TCKNESS MATERILAL
ft. 6 © ft. / / in. �Zf
Company Name c�
16.INNER,CASING_UR TUBLYG; eotherinal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICIavEss I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) Jt. ft. in.
3.Well Use(check well use): ft.J` , ft. in.
Water Supply Well: 17.SCREEN
FROM TO MMMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural- ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) [!]Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:•_GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft a,6 ft ewnm*6imd Poured
❑Monitoring ❑Recovery ft. ft
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
J9..;SAND/GRAVEL PACK if applicable)-
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. fL
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer .20.I)RIL-LIN..GLOG attach.idditionaI sheets if necessa y
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,g.rain size,etc.)
8 rt j et. b
4.Date Well(s)Completed: ID# ?I,; %3 ram- ft. ft
5a.2Werll Location: ft- ft- 2b r
3 b ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
6GIt a 1 t'[9'�L� i'yL>s�y u ft ft. t
Physical Address,City,and Zip
C P-f'�Yy`,F11-- 21:REIVIARIGS N A
County Parcel Identification No.(PIN) 2�2
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one ladlong is sufficient) 22.Certification:
N 7 ' S—S2 C3 5c W
6.Is(are)the well(s):immanent or ❑Temporary Signature of Certified ell 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 e i— 1 SA 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 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 ifdierent(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: Z 5 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+""
11.Borehole diameter: 6 (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,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
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) r1�� I� Method of test:
13b.Disinfection type: HTH Amount: e—,
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018