GW1-2022-08323_Well Construction - GW1_20220418

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
j e (L 1 ,14:WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3 ,779 , 3 70 ft. 7 ft j
it. rt
NC Well Contractor Certification Number 15.'0UTER'GASING`forpiulti case"d;wetls OR LINER if" tieatile
Barnette Well Drilling, Inc. FROM I TO DIAMETER THICKNESS MATERIAL
ft. 6 0 ft. 1; ,in. S R 2 v C
Company Name
I `JOANNER Cr+.SING OR'3 UBING` eotherma7 clos
3 G / ed loo ,,;•♦
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL Y
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
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in
❑Geothermal(Heating/Cooling Supply) [!]Residential 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 ft OUred
❑Monitoring ❑Recovery 0 ft att L.
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
-19.:5AND/GRAVEL PACKktLa"'lka41e
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control tt. ft
❑Geothermal(Closed Loop) ❑Tracer 207DRILLINGLOG attach additional sheetsi'ifinecessa_:
FROM TO DESCRIPTION(color,hardness,soiltrock p e, m size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
Q ft ft ae
4.Date Well(s)Completed: `Z Z Weii ID# 2 DQ:z ft. 6 fL g> I`
5a.Well Location: 6 ft. �� ft
C H e o yt, r R&. L o f 6,0 6-ft ft-
Facility/Owner Name Facility ID#(if applicable) SZ ft. tb6okt R
66 7z- tA3ooAf a.A.1 ft ft
Physical Address,City,and Zip ft ft t^� C^ �=
G R-g l r v i l/ao l 4 2 S'ooq to 9ge .2I:RENrARxs.
County Parcel Identification No.(PIN) R 9
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ..; ,,,
(if well field,one lat/long is sufficient) 22.Certification:
,,t�',,'lr:,.,iit'��1�="fit('.}_;. ,.,s��i•,
36. ?60ft3 g N 7f- 5`6 / W !'''
6.Is(are)the well(s): fffermanent 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 &No 15A 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 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: (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@I001
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: Z� (fk) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter 6 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
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: -n 24d.For Water Wells producinglover 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) �G. Method of test: /o�er Permit Program, 1611 MSC,Raleigh,'NC 27699-1611
13b.Disinfection type: HTH Amount: Cup L 7 t?
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018