GW1-2022-08393_Well Construction - GW1_20220418

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: !
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1.Well Contractor Information:
i .(�t,tJ Y�.1 P. �� (�`�+� .142'WATER-,ZONES
FROM TO DESCRIPTION
Well Contractor Name r Q',S— ft. O o ft.
a � 76 V0 176 ft. /90 et. �-
NC Well Contractor Certification Number CIS.OUTER CASING for.rriultl;caseit wells OR Z�1ERt;if'ii' lieable
Barnette Well Drilling, Inc. FROM TO DIAMETER in. THICKNESS MATERIAL
Q ft. ft Q Zt J U�
Company Name L �(
16.4NNER CASING OR TUBING."coEherfifal'cltiseil Too
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: SCREEN-
FROM TO'TM DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) l7Residential 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. Z_ 6 ft. Cement/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
k. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19i SAND7GRP2VEL PACK:rf; licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage IL ft.
❑Experimental Technology ❑Subsidence Control ft- ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRiLtING'LOG:attach atldi"tionalsheets'if,aecessa `
❑Geothermal(Heating/Coohng Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock ' e m s;ze etc.)ft
ft. ft. V.c`. (c..6 �(L�
4.Dace Well(s)Completed: �� �� ��i7Vell ID# 7 3 ft. /Z ft e,� i°'"r
5a.Well Location: ft. ft. lt>N r O i L/
Z91A&� ``ti 6-ft. 2-00c r4 a
Facility/Owner f4ame
L Facility ID#(if applicable) ft. ft
C`LL b ©ACT ft. fL
Physical Address,City,and Ap fL ft.
/_�.D;p.. ? _
County Parcel Identification No.(PIN) APR R W�O
5b.Latitude and longitude in de ees/minutes/seconds or decimal de
� �' degrees:g iYi��
(if well field,one ladlong is sufficient) 22.Certification: nfi.-- r� fnrtaZ{ )t?p4
�j 9967,Y
QtjJ./f�SM)I�..
3� NiT
5�5��S N 79, ! ! G Z g W
6.Is(are)the weD(s): @permanent 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 InNo I5A 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-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: go 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@200'and 2@1001
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 Iniection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC(I27699-1636
12.Well construction method:Ai r Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Droducin 2 over 100,000 GPD: Copy to DWR CCPCUA
QlA Permit Program, 1611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpm) �� Method of test:z,
13b.Disinfection type: HTH Amount: 6 O
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018