GW1-2022-08345_Well Construction - GW1_20220418

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: F
14'r WATER ZONES,,. .. _
FROM TO DESCRIPTION
Well
ContractorNamCe�' Q�
2 / [ l.�G ft eft l I
rt. it
NC Well Contractor Certification Number a15:OU�ER;CASING toc:mdlti ca§et�'wetls OR CINERt d"a Lcable
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
© ft. �( ft 6 !/g in. s'd Z t v C.
Company Name V
. eot6ermaPctosed-too" "- ..� � FROM
CAS NG.OR TUBING"" -
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): 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) gre-sidential 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 Qemeu SaF(d poured
❑Monitoring ❑Recovery O ft' e�Oft. ttf
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19'SAND/GRAVELVACK if "livable ,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft fL
❑Geothermal(Closed Loop) ❑Tracer .zfl�DRfLL4NG �G attach addiaonalstieets'ifnecessa'�"',
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size,etc.)
0 ft ft ace tv
4.Date Well(s)Completed: VY`2 Z Well ID# ft. ,Z ft f'
5a.Well Location: (Z ft. tt A 0
,5'a it&L rzp_-
Facility/Owner Name Facility lD#(if applicable) ft ft
Z Z 112DAIA 17'/l�f[t�v� �,,4h1� ft ft
Physical Address,City,and Zip r ft
�(���a�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Ce on:
36 51-78;ro N '? i3l B W Elluc
yr,.s
6.Is(are)the well(s): O ermanent or ❑Temporary Si 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 6Ko 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: Td V (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2@100)
,r 24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: 2-J (ft.) Information Processing Unit,161 T:MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: (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 Ope I-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health depart!meat of the county where Installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Well producing over 100.000 GPD: Copy to DWR CCPCUA
13a.Yield(gpm) Method of test:
/D� Permit Program, 1611 MSC,Raleigh,NC 27699-1611
-�_ _( �
13b.Disinfection type: HTH Amount: 19—ow
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018