GW1-2022-08327_Well Construction - GW1_20220418

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
4;WATER,ZONES
FROM TO DESCRIPTION
Well Contractor Name 7.5- it.
52 7,�� -old //0 ft. I Z-D ft- i 5-io.,09
NC Well Contractor Certification Number
J5."OUTER CASING(for tilti-iasedwdlls)OR CINER 0 alile�
Barnette Well Drilling, Inc. FROM I TO DIAMETER I TKICKNUSfa iMATERIAL
0 ft. 1 6 0 fL d f in. I �A<2
Company Name 46 INNER CASINGORTUBING'66thirmalclosed,1060)
2.Well Construction Permit 3 6 '3 .,7/ R FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits fl.e.UIC,County,State,Variance,etc.) ft It. in.
3.Well Use(check well use): ft. fL in.
17:SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE n
.THICKNESS MATERIAL.
CAgricultural 0Municipal/Public ft. fL in.
OGeothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft. It. in.
01ndustrial/Commercial OResidential Water Supply(shared) -18.,GROUT`
DIrrigation DWells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. fL CawA496end Poured
OMonitoring DRecovery ft ft. frlFifUsi
Injection Well: 0
ft. fL
0 Aquifer Recharge OGroundwater Remediation
I9.'SAND/GRA'VEI;PACK Ctf.appticablel
DAquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
0 Aquifer Test OStormwater Drainage ft. ft.
OExperimental Technology El Subsidence Control ft. ft
OGeothermal(Closed Loop) []Tracer ZOs DRILLING LOG'attach eddifioiial sheets if nei ease;
OGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock t"e,gmin size,etc.)
". if ft- 6 Ly r-P_1"-,aubso
4.Date We ii
ll(s)Completed: A 16 -2wo,ED# 3 �_-7 a-/9 ft.it- , ft'W OP-A r_1A
5a.Well Location: Cs 5-to ft Ro-a CUN To"
ft. ft.
& (Z R _k
Facility/Owner Name Facility ID#(if applicable) ft. L It.
ft. ft
Physical Address,City,and Zip ft. ft.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
r- -
6.Is(are)the well(s): ClPlekmanent or []Temporary Sign7ature of Certified Well Contractor 7 Date
By signing this form,I hereby certify ihat,the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or AM IJA 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 I GW-I 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: fe=6 .
(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 fo rm to.Division of Water Resources (DWR),
10.Static water level below top of casing: 17 (ft-) Information Processing Unit,1617IMSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: b (in.) 24b.For Injection Wells:Copy t I o DWR�Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC,27699-1636
12.Well construction method:Air Rotary 24c.For Water Sypply and Ove I Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.)
county environmental health department of the county where installed
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing,over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpm) Method of test: ecx
13b.Disinfection type: HTH Amount: "2F QW
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resource's Revised 6-6-2018