GW1-2021-05479_Well Construction - GW1_20210722

WELL CONSTRUCTION RECORD (GW-1) ��a For Internal Use Only: j
1.Well ontractor Information:
ont Ie �' Prw�� i
14:WATER ZONES 1' '
Well Contractor Name FROM TO DESCRIPTION ;
351r -� ft- -73 ft- -h Id o' o .-
rt. qS ft.
NC Well Contractor Certification Number r '
Inc. 15.OUTER CASING for.multi-cased wells OR LINER if a livable
Barnette Well Drilling, c FROM TO DIAMER ET THICKNESS MATERIAL
ft. &3 ft. in.
Company Name
16.INNER CASING OR TUBING geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. fL in.
3.Well Use(check well use): ft. fL in.
Water Supply Well: 17.SCREENFROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft fL in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft. ft. in.
❑Industria/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. Cement/Sand Poured
❑Monitoring ❑Recovery O ft. L? It. %A641
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL PACK if applicabte .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
[]Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOCr attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc.)
0 ft. ft. o lf" 4&de r
4.Date Well(s)Completed:S- 27 Z' Well ID# ft. S fL (lam /f
5a.Well Location: 557
ft. 4— fL S h4(C
i9w d i., s kN - ft 140 fQ <-%A/k
Facility/Owner Name Q �ry Facility ID#(if applicable) ft. ft.
i ,6s ft. ft. p
Physical Address,City,and Zip I
Ys ty, p A ft ft.
Rely 0^ Q >II03 gut 17 21.REMARKS
County Parcel Identification No.(PIN) J U L
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ^^Drn Izsing Ul rll
llivt 'r
(if well field,one ladlong is sufficient) 22.Certification: ���'I<...^,(.,'Poll
N W
6.Is(are)the well(s): [!]Permanent or ❑Temporary Signature of Certified Well Contractor' Date
By signing this form,!hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [INo 15A NCAC 02C.0100 or l5A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis 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 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: 0 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierent(example-3 200'and 2@100')
1
ar ft. 24a. For All Wells: Original forth to.Division of Water Resources (DWR),
10.Static water level below top of casing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: (in.) 24b.For Injection Wells: Copy�to'DWR',Underground Injection Control(IUC)
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) 3� Method of test: �[p u, Permit Program, 1611 MSC,Raleigh,NC 27699-1611
L.I �I I I
13b.Disinfection type: 1�L_ITH Amount: 1/L Cup
4
Revised 6-6-2018 Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
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