GW1-2021-00524_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
- le-. Pit us-' L f 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
yrud
J S-ft. 70
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Barnette Well Drilling, Inc. FROM TO DIAMETER THICK�iESS MATERIAL
6 ft. 6 Z ft 6 / in. d g --
Company Name
16.INNER CASING OR TUBING eother al closed-too
2.Well Construction Permit#: FROM TO I 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): it. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public tt. ft. in.
❑Geothermal(Heating/Cooling Supply) Ige--sidential Water Supply(single) it. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
❑hTi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft GetrmrdG&W Poured
❑Monitoring []Recovery a ft. rL� ft. t
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery El Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑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,soil/rock typc,grain size,etc.)
ft. ft n JP-�� 1 Q
4.Date Well(s)Completed: Z Z Well ID# Z_ ft' 2 ft 16 /`oJ
5a.Well Location: 1 L `t- 3 `t. f N� oIU E
lyoh Zo ss tQ L 0+ 9. 3 Sft. S-a fL G �q He
Facility/Owner Name Facility ID#(if applicable) ft. Zd ft. Q C�C.
o f �' Glie S 2 vla ft. it. )
Physical Address,City,and Zip ft ft.
21.REMARKS
County C Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I ';
(i£well field,one lat/long is sufficient) 22.Certification:
�30/ s 8 q N 79_ c 7l4<se W LA
6.Is(are)the well(s)• Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certift that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Mf'Po 15A NCAC 02C.0100 or ISA 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 oJ'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: Z D (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3@200'and 2@100D
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: Z s (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1f water level is above casing,use"+"
11.Borehole diameter: 17 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(RUC)
/�
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air 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 producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) / Z Permit Program, 1611 MSC,Raleigh,NC 27699-1611
Method of test: !!S(�i
13b.Disinfection type: U I H Amount: 1/2 Cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources \ Revised 6-6-2018