GW1-2022-06539_Well Construction - GW1_20220418

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: i
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1.Well Contractor Information: j
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;',U;WATER'zoNES s... r<.
Well Contractor Name FROM TO DESCRIPTION
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NC Well Contractor Certification Number :1$;OUTER EASING'for:multi,cese 'wells:OR LINER:'if a livable
Barnette Well Drilling[ Inc. FROM TO DIAMETER I THICKNESS MATERIAL
V ft. 6 ft. 6 ` in. ALIe Z t/C.
Company Name Q +lb.`13NNERCASING,OR�T:UBING `'otliermat�elosea=too' °--: _ .
2.Well Construction Permit#: /p O 7 FROM TO DIAMETER THICKNESS MATERIAL Y
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) % ft in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) CJResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ,g GROU x,
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft Poured
❑Monitoring ❑Recovery ft. 3d ft. ! �t
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL`PACK.d.a' li'❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. tt.
❑Experimental Technology ❑Subsidence Control ft tt
❑Geothermal(Closed Loop) ❑Tracer 20.DR11LLINC',L0G:attach additional sheets`ifnecessa '
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soiUrock .,ghi size,eta)
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4.Date Well(s)Completed: 2-if-2-7- well m# 40 Z ft ft j
5a.Well Location: 15- fL ar It- ", S
tt.
Facility/Owner
Name( �/Facility 1D#(if applicable) 7 ft. Z b Q tt 'd l
Zy i V�l� yI )-t,pl & ft ft
Physical Address,City,and ip ft ft n E_ .
;21':REMARKS=. ,--
GNswell 6 / `7 fl 202�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification
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3-IC• y60 23 N - > 7 2- V e w
6.Is(are)the well(s): �'Pel manent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I herebv certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or &Wo 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 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: -7-6 0 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@I00�
10.Static water level below top of casing: -Z S (ft.) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
Information Processing Unit,16171MSC,Raleigh,NC 27699-1617
If water level above casing,use op
11.Borehole diameter: b (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC'i27699-1636
12.Well construction method:Air Rotary
24c.For Water Supply and Operi-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
/Q / Permit Program, 1611 MSC,Raleigh,'NC 27699-1611
13a.Yield(gpm) y�in a I Method of test: / �y
13b.Disinfection type: HTH Amount: a
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018