GW1-2021-00511_Well Construction - GW1_20210315

WEI.I.CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
� L(p� 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
9a ft. it. .4-a Jq
3b
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name
O ft. Y- ft. 6 l in. ,, o 1?L L.--r-
o' 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: Lei/ FROM I TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. rL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) nResidential Water Supply(single) ft. ft. in.
❑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. ft. CamewRkpd Poured
❑Monitoring ❑Recovery O ft. z.�D ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑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 necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,saii/rack type in size,etc.)
� rt. Z rt. P fL 6 w�
4.Date Well(s)Completed: Well ID# W?,O-yZ ad ft• ft.
5a.Well Location: ft .3 O ft.
ciA 42k&/f&"9s o ft. 7 - ft.
Faci
LlitytyO` / �ft
er Name �I v r Q/O Facility ID#(if applicable) . o it.
8' - /0 U -U. ft ft. -_'
`.�.z
Physical Address,City,and Zip ft. ft.
a f&6414e ly7p' 7 21.REMARKS -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification: iy'.`,V
N q. s 2 3'72 W s
6.Is(are)the well(s)• efPermanent 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 MWiu- ISA NCAC 01C.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
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9.Total well depth below land surface: �-T (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 2Q100D
10.Static water level below top of casing: 2 e (ft) 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: (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well constriction method:~i r Rotary
(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: Copy to DWR,CCPCUA
13a.Yield(gpm) 16 Method of test: ,, Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amoutr4 v�"1' 1� /
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018