GW1-2022-08351_Well Construction - GW1_20220418

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
/ e ft.
, O f L Z
/ ?6 ft. t o A JA t It o d I
NC Well Contractor Certification Number 6Sft. /g15.'OUTER CASING`(for multi cased.wells ORZINER':if a" livable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name Q ft Z fL to 5443•1q-t,
6.INNER CASING OR INGIgedthermid.closed-166111
-loo
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, variance,etc.) fL fL 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) �dential Water Supply(single)
ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) :18:_GROUT
Oh-rigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft- fL Cement/Sand Poured
❑Monitoring ❑Recovery ft. fL
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK (if-applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothenmal(Closed Loop) ❑Tracer 20.DRILLING LUG attach addiiidnal-sheets if necessary)
❑Geothermal g ) FROM TO DESCRIPTION(color,hardness,soilfrock a in size,eft.)
(Heating/Cooling Return) ❑Other(explain under#21 Remarks
!6 a ft it It. ov e-R 1p�QaA ac
4.Date Well(s)Completed: - ���=Z�We11 ID# 00 tt, V-t tt, IPt-0 L yOU S y e
Sa.Well Location: ., thft If' IL 1"IL&;'O0-4r--,
eAEie d-J_clC� el���y CSC-tt. yontt G Q
Facility/Owner Name
Facility ID t,
#(if applicable) ft. f
1(4 6 1t A /JeA w f a CpS'4-e.-g-A � 4� ft. ft.
Physical Address,City,and Zip /` ft. fL
e,, /U�� �J 21'REMARKS
County Parcel Identification No.(PIN) R 14^
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Q
(if well field,one lattiong is sufficient) 22.Certification:
N 7 1 _ 33 zG W
6.Is are the wells• e Signature of Certified Well Contractor s Date
Is(are) (). meat or ❑Temporary s"'i Y Fn "j�
1. a�aTr�,
By signing this form,I hereby certify that the i4 fs)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Ali- 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: 2-b a (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 t@20d'and 2®100D
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: (ft-) Information Processing Unit 1617 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,NG 27699-1636
f
12.Well constriction 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
13a.Yield(gpm) 2-� Method of test: alor..-� Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.-Disinfection type: HTH Amount: $0 cup SJ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018