GW1-2021-05740_Well Construction - GW1_20211015

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information:
/ �� �� t.((` 14.WATER ZONES l
Well Contractor Name FROM TO DESCRIPTION
7f ft. 1?0 ft 6 0--r(
NC Well Contractor Certification Number
1S.OUTER CASING for multi cased wells OR LINER if a livable
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name
//�'] 16.INNER CASING OR TUBING- eothermat closed-loo
2.Well Construction Permit#: // o FROM TO DLIMETER TffiCKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, variance,etc.) ft. ft, in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17..SCRFRN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. It. 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 FROM TO MATERIAL EMPLACEMENT METHOD&AMOUW
Non-Water Supply Well: Q ft. O ft- CemenVSand Poured
❑Monitoring ❑Recovery tt. ft
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salmi Barrier 19.SAND/GRAVEL PACK if a i ticabie
ty FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control fL ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM ft. TO DESCRIPTION(color,hardness,soil/rock e,grain size,etc.)
Q ft p U b f tP_
4.Date Well(s)Completed: "� 'Z/ Well ID# ft. CO ft. 1 1� q< S Q I
5a.Well Location: ft. ft - D\
e111 � r�/
ifNT f C SC ft ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ft. ft
Physical Address,City,and Zip ft
6 f,. g /Q 21.-REMARKS
County Parcel Identification No.(PIN) J i1Z
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: anti
(if well field,one lat/long is sufficient) cs 22.Certification:
6.Is(are)the well(s): nIF-ermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I herebv certify that the well(s)was(were)constructed in accordance with
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7.Is this a repair to an existing well: ❑Yes or N'o 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 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-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: /e56
For multiple wells list all depths ifdifferent(example-3Q200'and 2�100� ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 2. 5 (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
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11.Borehole diameter: p (in.) 24b.For Injection Wells:Copy to,DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
(i.e.auger,rotary,cable,direct push etc.) th.Well construction method: Air Rota 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to e
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD• Cop
y to D WR,CCPCUA
13a.Yield(gpm)
Z Method of test: A7", _n Permit Program, 1611 MSC,Raleigh I,NC 27699-1611
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13b.Disinfection type: HTH Amount: 1/2 Cup
Form GW-I North Carolina Department of Environmental Qualitv-Division of Water Resnurces oe.,: