GW1-2022-07307_Well Construction - GW1_20220809

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES {
FROM TO DESCRIPTION
Well Contractor Name /q Z�ft. ft.
31 6 .5'a ft. Q ft. / f / b S�d !� ✓
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased!,wells OR LINER if a licable
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
LJ 0ft. /• fL 6 A in. S 21 UG
Company Name ��qq 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: 2 Z tl Z y FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. tt. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
,
❑Geothermal(Heating/Cooling Supply) �Rlrldential Water Supply(single) ft. ft. in.
❑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- 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 EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control fL ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiltrock e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
22 ft .r ft 1/e2�W�ti
4.Date Well(s)Completed: 'ZJ"ZZWell ID# � OtJ2 ft. 2 Z ft. �� sd,
5a.Well Location: 1,11 2.2,ft. v ft.
ft. Z ft. 4r_-,x-3
Facility/Owner Name Facility ID#(if applicable) ft. ft.
L.t� C n QN wa I!i S eC�Q rt. rt
Physical Address,City,and Zip ft. ft.
N � !
o e, qa 2-� �2 G 2R? 2L REN ARKS _
County 9V Parcel Identification No.(PIN)
f1f:^_<--*vv,�';9 lJnd
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36forF, e3 N `747 _ 001 7-7 W
6.Is(are)the well(s) ermanent or ❑Temporary Sign ture o Ce ified 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 171Vo 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 oJ'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 I 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: 2 i�!) (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@100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Z� (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
11.Borehole diameter: (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) 3 O Method of test:
Permit Program,1611 MSC,Raleigh,NC 27699-1611
/� 4
13b.Disinfection type: HTH Amount: . �73 0 �.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018