GW1-2021-05602_Well Construction - GW1_20211015

WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contr ctor Informatio :
1 � # l
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
y 14 rt. 75
ft.
Z trU ft. 2(` ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells)OR LINER if a livable
Barnette Well Drilling, Inc. FROM TO t TER THICKNESS M
ft. Q' ft � in. f
Company Name a
3 (�!� � c, 16:INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: V ! FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) (IResidential 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 It- Cemerit/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.'SAND/GRAVEL PACK'dapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL 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,soil/rock type,grain size,etc.)
�r rt. tit. U�PJq Gr
4.Date Well(s)Completed: Z Well ID# ft. z fL r7G C
5a.Well Location: ft. ft
/\lb-e� 1��CILI� ( �Z�r'Ja�� ylP/�Z ft ft
Facility/Owner Name r� Facility ID#(if applicable)
(Q u W O [h k 4 `/7 ft. ft.
Physical Address,City,andZip Ok / ft 1
�r) 77 A'W I/t l(/ 21.'REMARKS
County Parcel Identification No.(PIN) -`tri 31`t?11 t
1�c+
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iattlong is sufficient) 22.Certificgtion:
7( 27, 07 N ¢ �3t3 W q1MAI
6.Is(are)the well(s)• VPermanent or ❑Temporary Signature of Certified Well Contractor Dat
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 *0 15A 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 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 2 O (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'annd�2@100)
10.Static water level below top of casing: J " (ft.) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
If water level is above casing,use"+ Information Processing Unit,1617,MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (D (in,) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air Rotary 24c.For Water Supply and Open LLoop 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 producinjover 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: HTH Amount: 1/2 Cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018