GW1-2022-08349_Well Construction - GW1_20220418

WELL CONSTRUCTION RECORD GW-1
For Internal Use Only:
I.Well Contractor Information:
i
Well Contractor Name 14.WATER ZONESFROM TO DESCRIPTION
NC Well Contractor Certification Number fit ft. g
Barnette Well-Drilling, Inc. 15.UUTERSCASING formtilti=¢'s ed.wells ORLINER;t`faC'�liAcable FROM TO DIAMETER THICKNESS MATERL4L
Company Name 0• ft• 6
z ft 6 � in. S tz zl Pvt,
2.Well Construction Permit# � 16:�1NNEWCASING OR'TUBING. 'eotherriW osed-loo
FROM TO DWMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State, Variance,etc.) ft fL in
3.Well Use(check well use): fa ft. in.
Water Supply Well: '17.'SCREEN
❑Agricultural FROM TO DIAMETER SLOT SIZE T HICKNESS MATERIAL
❑MunicipaUPublic ft. ft. Vin.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
❑Industrial/Commercial ft. ft. in.
❑Residential Water Supply(shared)
❑Irri ation 19.,GROUT
❑Wells>100,000 GPD Non-Water Supply Well: FROM To MATERIAL , EMPLACEMENT METHOD&AMOt1NT
❑Monitoring ❑Recovery t` t7 R' Cement/Sand Poured
Injection Well: ft. %
❑Aquifer Recharge ❑Groundwater Remediation it ft.
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL_PACK if a—Iicable
❑ FROM TO Aquifer Test ❑Stormwater Drainage tt ft. MATERIAL EMPLACEMENT METHOD
❑Experimental Technology ❑Subsidence Control ft, ft.
❑Geothermal.(Closed Loop) ❑Tracer 30.DRILLING LOG.attach additionahsheets:if necessa
❑Geothermal(Heating/Cooling Kelton) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soillro gmin size etc.)
o ft. e
4.Date Well fts)Completed: Well ED# �^ it. V
Yoe
5a.Well Location: ft. �+M
Facility/Ownerft.
,9
- Name Facility ID#(if applicable) ft .
Physical Address,City,and Zip ft ft. 1S,Tm p d a p '
�, -ks d ,/ 7�' 11.XEMARKS
County Parcel Identification No.(PIN) Z•'
+aa5�a
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `' Ibtir"i'il 4
(if well field,one Iat/long is sufficient)
22.Certification:
3 if,3S1o9 N _ -7 a� 0 32 w
6.Is(are)the well(s): Aftermanent or ❑Temporary Signature of Certified Well Contractor Date
gning
7.Is this a repair to an existing well: ❑Yes or ONo 1 AINCAC 02C.01001ereby or 1SAcerti NCAC 02C.0200fy that the1(Well Const ct onstructed Standards and that ain accorecwith
opy
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:
Z D 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below laud surface: (ft)
For muhiple wells list all depths ifdierent(example-3Q200'and 2@1000 Submit this GW-1 within 30 days of well completion per the following:
Z� (ft.) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing:
If water level is above casing,use ,+• Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Air Rotary
program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: '1
(Le.auger,rotary,cable,direct push etc,) 24c.For Water Supply and Open-Loop Geothermal Return Wells Copy to the
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
13a.Yield m �! Pemtit Program,1611 MSC,Raleigh,NC 27699-1611
(gp ) Method of test:�q..b�(�t,M,�=
13b.Disinfection type: HTH Amount: /G Q
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources f R-A-A F_F_,n,v
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