GW1-2022-08337_Well Construction - GW1_20220418

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Tflontractor Information:
37.y 44r WATER'ZONES
Well Contractors Name FROM TO DESCRIPTION
�
c�/ Zee, 6 ft. ft Z!�,
ft.
NC Well ontractor Certification Number ZO ft -�
3 Z 1/
15.;OUTERCASING_for;mtilHeesefiwells<OR'L•INER if•a' Iica6le
Barnette Well Drilling Inc. FROM TO DIAMETER THICKNESS MATERIAL
r ft. 2 ft G k in. 2
Company Name
1� ]6:`INNER,CASIISG OR TUBING.:(&othermal closed;too a.-•
2.Well Construction Permit#: s FROM TO DIAMETER THICKNESS MATERIAL
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.
-17i.SCREEN;;C;
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared)
18 GROUT°
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL _ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. fL Gew&WdSend Poured
❑Monitoring ❑Recovery ft. ft. Q
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GR&1V,'EL"PACK,ifa`l ltcable
❑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:DRILLING-LOG.af_tech-eddriofaatsheets:iinecess
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardn soil/rock a in size eta)
b tt. it. a i R ��,C�
An PJ
4.Date Well(s)Completed: ZL Well ID# ft. e
5a.Well Location: S ft. 36 ft
faial C /-C 1q* Ke� ft. 1,- — ft dCrL
Facility/Owner Name I Facility ID#(if applicable) J,-ft Q It. L CUB
ft. ft
7
Physical Address,City,,and Zip ft ft i
pe SIC! %/ 21_;REMAItKS:
;...
b rt 1 '
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
36. 2_6/ 71 N 79, Q 3,? Z 3 w �; F'"`r'1%
6.Is(are)the well(s): 5Per nfanent 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 &NT— 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.SUBMTTTAL INSTRUCTIONS
9.Total well depth below land surface: f �}0 (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: 2 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+- I
24b.For Injection Wells:Copy o DWR,Underground Injection Control(TUC)
11.Borehole diameter: O (in.) ti
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
/e'illea Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 2S Method of test:
13b.Disinfection type: HTH Amount: Uz Cup Ks
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018