GW1-2021-05741_Well Construction - GW1_20211015

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Zontractor Information:/�i�y 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
7 — Ate° Q
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NC Well Contractor Certification Number 15.OUTER CASING for mullh caseed wells OR LINER if a licable)
Barnette Well Drilling, Inc. FROM TO DIAMETER HI TCKNESS MATERIAL
Company Name h ft / z t. �5 in. 1 ��
�/f�p� 16.IINNER CASING OR TUBING 'eothermal closed-loop)
2.Well Construction Permit#: /l f/ FROM TO DIAMETER I THICKNESS MATERL4,L
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.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERLII.
❑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
❑Irrigation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 6ft- Cement/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK-Sa licable
❑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, oiltrock e,,rain size,etc.)
rt. rL 6 vcrk b csi cr
4.Date Well(s)Completed: r�Z Well ID# A(p �� ft. 0 ft. ja _6�
5a.W ll Location: it. 7—O ft fti �
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Facility/Owner Name Facility ID#(if applicable) ft. ft.
ft. ft.
Physical Address,City,and Zip ft ft.
r
fle�<_® _ ) ?`r 21.RE11iARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certtification:
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6.Is(are)the well(s): "e manent 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
7.Is this a repair to an existing well: Dyes or 11p 6 I5A 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#11 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: C `6 (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)
10.Static water level below top of casing: Z,5— 24a. For All Wells: Original formW to.Division of Water Resources (DR),
(fk) Information Processing Unit,1617IMSC,Raleigh,NC 27699-1617
If water level is above casing,use"++"
11.Borehole diameter: 6 (in,) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC Q7699-1636
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 over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Z Method of test: �(J Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: H t ulu n Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018