GW1-2022-07310_Well Construction - GW1_20220809

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.WelZ79
r Information: �y
� I�G��L�1 C 14.WATER ZONES
Well ntractor Name FROM TO DESCRIPTION
ft ft.
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
d ft. q� ft G H � In. � Zl 7lrC
Company Name
16.INNER CASING OR TUBING eo'thermal closed-loop)��/
2.Well Construction Permit#: 1 �j D FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State. Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft fL in,
❑Geothermal(Heating/Cooling Supply) L9Residential Water Supply(single) ft. ft in.
01ndustrial/Cormnercial ❑Residential Water Supply(shared) 18.GROUT
❑hTi ation ❑Wells>100,000GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: v ft. O 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 I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiltrock type,erain size,etc.)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks)- D fL ft (71
4.Date Well(s)Completed: 6 aZ Well ID# 0 _ ft• e6p ft ,pl/ "S [-"e
5a.Well Location: !r� ft, 2-DJ fL <a dj, ,e
ft. SD ft
Facility(/Owner Name 1/ / Facility ID#(if applicable) ft. ft.
V y„,M ( ��ot/Gyl fL ft. E�- E IV E
Physical Address,City,and Zip ft fL
21.REMARKS -
County 7 Parcel Identification No.(PIN) �� 'mil �'"�� UD'h
J,VQi3�:T
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifi lion:
�36" (S(64T_ N ?Y° Lf q9 t`l 3 W
6.Is(are)the well(s): CJPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 01C.0100 or 15,4 NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out brown well construction information and explain the nature of the of this record has been provided to the ivell 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: f 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ✓U0 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2@1001
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: a (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(IUC)
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
(Le.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
ao t�`1
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: Ow
�1
13b.Disinfection type: HTH Amount: 1/L Cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018