GW1-2022-08360_Well Construction - GW1_20220418

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
4W 1-C Lk ,�14;'-WATER ZONES:.,-
Well Contractor Name FROM TO DESCRIPTION
?
z .-::fi //0 ft. -Ll.,r , L-T'o
3,;;p t
NC Well Contractor Certification Number ?,D I
THICKNESS C j
cable
Barnette Well Drilling, Inc. FROM TO DLAMETER S MATERIAL
Company Name ft ft. 6 t�il in. I r I rV
I ..]NNM C
NNEIC -SING�OR TUBING �ddsed�2.Well Construction Permit#: 31r7 6 2 a FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits rz.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
,17.'SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SUE THICKNESS MATERAL
DAgricultural DMunic' al/Public ft. ft. in.
u c DGeothermal(Heating/Cooling'Supply) Ze.sidential Water Supply(single) fL ft. in
Dindustrial/Commercial DResidential Water Supply(shared)
ObTigation OWells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft- Celx Poured
OMonitoring ElRecovery A ft, 7C) ", >
Injection Well: fL ft.
0 Aquifer Recharge ElGroundwater Remediation
.19..:SAND/G]1AV,EL PACK(if applivable .".-:.,
DAquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETH D
DAquifer Test 0 Stormwater Drainage ft. f,
0 Experimental Technology 0 Subsidence Control ft. fL
DGeothermal(Closed Loop) OTracer
DGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM . TO fL DESCRIPTION(color,hardness,soiltrock type,gmin size,etc.)
4L 6 Li R-X 6 W-2
4.Date Wells)Completed: z we,,iD# 7 S ft
-3 6 -2 li- ft- 2,9- fL e7 m V
5a.Well Location: ft. ft- X!&LV S &
AV 1-ildelegg -7 .0 2-tN e!AA QeN C
Facility/Owne/Name Facility rD#(if applicable) ft. ft.
16 -2 1 S. h ek fL fL
Physical Address,City,and Zip ft.ft. PIP rIPTV� I
r_-.x?I "(-i q 44
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification: my Mi"a U
w- 0
I
Ph)Y V N 7 q,?5-7 w C
6.Is(are)the well(s): immanent or OTemporary 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: DYes or &N-6- 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 I GW-I 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: z-0 CS (ft) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100) i
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"+- 24b.For Injection Wells: Copy to
9 DWR,Underground Injection Control(TUC)
11.Borehole diameter:- Ic (in.) Program,1636 MSC,Raleigh,NC 1 27699-1636
12.Well construction method:Air Rotary i
24c.For Water Supply and upeuLoop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,directpush,etc.)
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producinalover 100,000 GPD:Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,!NC 27699-1611
13a.Yield(gpm) 7—CD Method of test:
13b.Disinfection type: HTH Amount: I&CUP
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018