GW1-2022-06008_Well Construction - GW1_20220615

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Tontractor Information:
�1�i �� 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft' 0
00,
1 y/` ? U w J It.
ft. -i z
NC Well Contractor Certification Number 15.OUTER CASING(for multi ed wells)OR LINER(if a licable)
Barnette Well Drilling, Inc. FROM TO DIAMETER I THIC"ESS MATERIAL
Company Name .
0 ft. &12 ft ' �'t1 in. Sp 2( VC
T i .16_�INNER,CASING OR TUBING;(geothermal closed-loop)
2.Well Construction Permit#:,I CV` 1� A-' C r �,�j FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits fl.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN -
PP Y 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 .
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft J ft 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 Barrier FROM TO MATERIAL EMPLACEMENT METHOD
[]Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer ..20A)RILLING-LOG attach-additional sheets.if necessary).
FROM TO DESCRIPTION(color,hardness,soillrock e, ain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) D ft. Z- ft' LIP�--
r / s
4.Date Well(s)Completed: S t'�—�Z. Well ID#L M" 62 ft' (C4 ft r
c
5a.Well Location: 1 ft. ft. J oa ,OL IC
ft. 3 yJ ft Tcz f 9 lu r :L'9
l�C!(/l U Ull ILi v� ft. ft
Facility/0 er Name Facility ID#(if applicable) •T n: -•-"
ft. ft. 7
Physical Address,City,and Zip ft ft. JUN
it�� Q' :21:,REU'IARKS _•_„yc-t�:a i`� . , •`
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattloonng is sufficient) Q / 22.Certification: n
L Ll 5'( N 16 W ,�,,,,
6.Is(are)the well(s): InPermanent 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 InNo 15A NCAC 02C.0100 or ISA 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: !� C (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3@206'and 2@100D
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: 2— (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
f I� 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: tC1 (in.) 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) I e'� Method of test:�&c9%.J Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1/2 Cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018