GW1-2021-00880_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD (GW For Internal Use Only:
1.Well Contractor Information: _
"WATERWe11Con[ractorName DESC7d A oft' �ft.NC Well Conhactor Certification Number for multi cased wells OR LINEBarnette Well Drilling, Inc. DIAMETER TIIICKNEss < , ERIALCompany Name ft in,
( ? 16.INNER CASING OR TUBING(geothermal closed-log
2.Well Construction Permit#: w �7 FROM TO DIAMETER THICKNESS
J MATERIAL
List all applicable well construction permits(l.e.UIC.County State, Variance,etc.) fL ft. in.
3.Well Use(check well use): ft; rL in.
Water Supply Well: 17.SCREEN
❑A Cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL,
❑MunicipaUPublic ft ft. in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single)
ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
18.GROUT
01rri ation ❑Wells>100,000 GPD FROM Non-Water Supply Well: ft. TO MATERIAL EMPLACEMENT METHOD&AMOUNTft.
❑Monitoring ❑Recovery Geffie,��� Poured
,
Injection Well: o ft �R. � ��
❑Grou
a R
❑A uifer Recharge ft. ft.
q g ndwater emediation
[]Aquifer Storage and Recovery19.SAND/GRAVEL PACK'if a livable
❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM ft. TO ft. DESCRIPTION(color,hardness,soil-- e, rain size,etc.
�g Q Q �
4.Date Well(s)Completed: z 6=�/ Well ID# -- Z 3-f 72 5' ft• ft fig LA-Q&O A—,-1e� G�
Sa.Well Location: f ft. ft, s. G
1160 fL
Facility/Owner Name y Facility ID#(if applicable) O b' 2 60'
� d d /9 Al / /,,V fL ft fK °
Physical Address,City,and Zip ft ft. j-'a' 'i.s'A—
CR&��/r 0% J]-f� 7 L,6 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Linii
(if well field,one lat/long is sufficient) t
22.Certification:
6
• s8zs� N _ 78 . 5 6 2_97 W
6.Is(are)the wlll(s): 8rermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I herebv certifv that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MW5— ISA 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-l 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 ,D
For multiple As list depths if different(example-3Q200'and 1®100D
(f t) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: ) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
Ifwater level is above casing,use"+ / Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: O (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
12.Well construction method:~
I�i r Rotary Program, 1636 MSC,Raleigh,NC 27699-1636
(i.e.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• Co D
Pemmt Program, 1611 MSC,Raleigh,NC 27699-1611 Copy to CCPCUA
13a.Yield(gpm) � Method of test: Alt)/
13b.Disinfection type: HTH Amou A-1/2 Cup
Form GW-1 North Carolina Department of Environmental Oualitv-Division of water Resnurcec 1,