GW1-2022-07318_Well Construction - GW1_20220809

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased ikw OR LINER(if a livable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
O ft. ?1L 1 6 I in. Z! f>
Company Name
�© 16.INNER CASING OR TUBING ebthermal closed-loop)
2.Well Construction Permit#' 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): it. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft, ft. in.
❑Geothermal(Heafing/Cooling Supply) InResidential Water Supply(single) fL 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. 32,� ft. Cement/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
fL 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. fL
❑Experimental Technology ❑Subsidence Control fL ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rack e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft
(l`C1�.T cg16
4.Date Well(s)Completed: 16 1-y':'O.; Jell ID# J® ft. !o ft. a SJ
5a.Well Location: t ft. 46 ft 0 fL l St S Al6A If {C
C'hR i� tai@.: � Ces b rt. g n
Facility/O��wnne�erName Facility ID#(if applicable) ft. ft.
fL
Physical Address,City,and Zip fL
21.REMARKS
1 AUG 0 9 2022
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I imfe' a;4o'. ,p uno
(if well field,one lat/long is sufficient) 22.Certification: DVVQ!8OG
76 5-Z- N 7.9'• Qg 7 4g wPYX�2 L_\ J�_ df;��r A
6.Is(are)the well(s): ZFermanent 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 @WV' 1 SA NCAC 02C.0100 or 1 SA 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 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(IUC)
11.Borehole diameter: V (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
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Permit Program,1611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpm) Z Method of test: A/6
13b.Disinfection type: HTH Amour. ly Z
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018