GW1-2021-05605_Well Construction - GW1_20211015

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Con r for I formati
/? VL 14.WATER ZONES ¢
FROM TO DESCRIPTION
Well Contrac or(NName its
C ft.
ft. f0 7 ft.
NC Well Contractor Certification Number Inc15.OUTER CASING(for multi-cased wells)OR LINER if a licable
Barnette Well Drilling, c. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. I in.
Company Name
� "� ! / /� _ 16.INNER-CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: C� .) G V FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) it. ft. I in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. rt. in.
❑Geothermal(Heating/Cooling Supply) nResidential 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. w�f ��ft• Cement/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquiecharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑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)
❑Geothermal(Hearing/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiltrock e, rain size,etc.)
f rt. 7- rt. v e�i If ,e
4.Date Well(s)Completed: 1 Well ID# Z S It.
U ft.
5a.Well Location: ft. ft.
L?D 5S Ft s ft. ft
Facility/Owner Name Facility ID#L applicable) ft.
7 S Y z C D 01VLe.?1*U K ft. ft
Physical Address,City,and Zi ft ft. `'` rJ )!
to .37/J �-P W" !S 170 0 J 21.REMARKS c�,�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/lonng is sufficient) G 22.Certifica n
[ 5 L/G/N � J l i L Z W
L
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor D
By signing this form,I 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 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: `' (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q206'and 2@100)
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing:
(ft') Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
Ifwnter level is above casing,use
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) 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 lover 100,000 GPD: Copy to DWR,CCPCUA
f p 13a.Yield(gpm) Method of test: Permit Program, 1611 MSC,Raleigh,NC 27699-1611
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