GW1-2021-05604_Well Construction - GW1_20211015

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES {
WellwContractor Name FROM TO DESCRIPTION
rt.
NC Well Contractor Certification Number
15.OUTER CASING for mulfirased wells)OR LINER if a livable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name D rt. S 6 ft. 6 � in. -t
g 16.INNER CASING OR TUBING 'eothermal closed-loop)
�J
2.Well Construction Permit#: r� 76- FROM I TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft, tt. in.
3.Well Use(check well use): tt. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation ❑Wells> 100,000 GPD FROMI I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: rt. ft- Poured
❑Monitoring ❑Recovery a tt. ft. eE
�.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a livable .
❑Aquifer Storage and Recovery ❑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)
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
C G ft fL
tj oe-le-C Lin",
4.Date Well(s)Completed: Well ID# 7, s ft. tL .$e-I
5a.Well Location:
eeZ,C- r, 0lr'. 4-,- 3.-Ltt. 70 f` Sly • 5-A onl
Facility/Owner Name Facility ID#(if applicable) 70 It. A�in o fL
Physical Address,City,and Zip ft. ft. F as 3
f G� p ly «� �,.�-,Z,z60p I ✓ �� 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.C,erCertification:n:
6.Is(are)the well(s): I!YPermanent 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
if 7.Is this a repair to an existing well: Dyes or W I5A NCAC 02C.0100 or 15A NCAC 02C.0200 well Construction Standards and that a copy
Ijthis is a repair,fill out known well construction information and explain the nature ofthe 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: T Ut b (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 2@100')
Z.� (ft. 24a. For All Wells: Original form
If to.Division of Water Resources (DWR),
Static water level below top of casing: ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" k
6
11.Borehole diameter: 6 (in.) 24b.For Iniection 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,directpush,etc.) county environmental health department of the county where installed
1
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producingiover 100,000 GPD: Copy to DWR,CCPCUA
����� Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) � Method of test: / I
13b.Disinfection type: HTH Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018