GW1-2021-05611_Well Construction - GW1_20211015

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Conti ctor Informatio
/ `e j /4 lieA/0 14.WATER ZONES i
Well Contractor Name FROM TO DESCRIPTION
Z y 1 i 4 p rt. ft � I
NC Well Contractor Certification Number
zD"v ft 2 fry ft.
15.OUTER CASING for multi-cased wells)OR LINER if a livable)
Barnette Well Drilling, Inc. FROM TO ft. (7 It. DIM TER in. TH I ICKNESS M
/n
Company Name
Z J` Cj 16.INNER CASING OR TUBING a thermal closed-loo
2.Well Construction Permit#: ,J [ FROM TO DL.METER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UlC,County,State,Variance,etc.) ft. �Lp t7 ft. in ( r�
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO I DIAMFTER! SLOT S1ZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public rt. ft. I
❑Geothermal(Heating/Cooling Supply) In Residential Water Supply(single) ft IL
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD&&MOUNT
Non-Water Supply Well: ft rt. CemenUSand Poured
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharga ft. ft.
Remediation❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK ifa livable
rn
FROM TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft. ft
i
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets it necessary
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,solurock e, rain size,etc.)
O ft. U ft.
4.Date Well(s)Completed: * U Z Well ID# ft. Z 2& ft
5a.Well Location: ) {� / G ft. ft
��f)`J'-eel / /f C(L t/b ( 11 Z Cep [`2 Y&k Z ft ft
Facility/Owner Name Facility ID#(if applicable) ft
A? ft. ft.
Physical Address,City,and/Zip ft ft.
C T7,fLlu4,1l( 21.RE MARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certific9tion'
z J, d ? N - , 3 W
6.Is(are)the well(s): Oermanent or ❑Temporary Signature of Certi ed well Contractor Dat 2
By signing this form,l hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Q�To 1 SA NCAC 02C.0100 or 1 SA NCAC 01C.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. i
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-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: � 2 O (ft.)
For multiple wells list all depths if different(example-3Q200'and 2Qa 100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 7 (ft) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
!/'water level is above casing,use"//+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: i0 (in.) 24b.For Injection Wells: Copy to IDWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Rotary i
(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: i
24d.For Water Wells uroducint=_over 100 000 GPD• Copy to DWR,CCPCUA
13a.Yield m 1 Permit Program, 1611 MSC,Raleigh,'NC 27699-161 I
(g ) Method of test:
13b.Disinfection type: HTH AmDnnt: 1/2 Cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resnnrrnc