GW1-2022-08332_Well Construction - GW1_20220418

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
<(&
We1lContractor Name FROM TO DESCRIPTION
� 0 G rb rt. /&o ft.
NC Well Contractor Certification Number 3 Q ft. 3� ft Z �O R'r
35.OUTEACA§ING;for:m'Wfi-cased webs 02i INER+"if4ificatile•.
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
/f ft. 7K ft 6 fib in. SJZ Z 1 l L
Company Name V
Ab.'-INNERC.A$INGOR.T[TBINGc"ottiermal-.clo§edi'oo
2.Well Construction Permit#: 2- FROM TO DIAMETER THICKNESS MA +ter v
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. % in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17..SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Mresidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) `18.�GROUT , -
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d it- ft- Cement/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL•PACK'ifa .licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20;'V RILLING:LOG attach additionifsbeeis if necess''
FROM TO DESCRIPTION(color,hardness soiltrock p e, in size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) G ft. 6 ft.
4.Date Well(s)Completed: I ff-2 2-Well]D# 3� _ en ft. ft it,*s
5a.Well Location: S`r ft. G ft.
J In /A5 1.1, �� tt 6 ft a /q d G'/
G
Facility/Owner Name Facility ID#(if applicable) ft. ft.
t,&t is 0X f �� ti7K ft. fL
Physical ,Address,City,and Zip / ft. ft.
PC leS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification'
�6 .S/7 69 N 7 9• D 6 G�� W � � / 2$`'22.
6.Is(are)the well(s): &K-rmanent 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 PJ1go 15A 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 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@I00�
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: Z s (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: a (in.)
Program, 1636 MSC,Raleigh,NC(27699-1636
12.Well construction method: Ai r 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
®� Permit Program, 1611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpm) �u u Method of test:�Y!['�� �
13b.Disinfection type: HTH Amount: �`T ep
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018