GW1-2021-05743_Well Construction - GW1_20211015

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES I
Well Contractor Name T- FROM TO DESCRIPTION
rt. .�5 tt. / �
(� /7S`ft- i$O 1-
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
V ft. 6 .? ft. t7 /,yir in. {C Zl l�Uf%
Company Name ge
16.INNER CASING OR TUBTVG(geothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS 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.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) 98.GROUT
❑Irri ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. eemen Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well: O ZO �i ��
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❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK iLapplicable)
._ .. .:_:.....
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. it.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary).
❑Geothermal(Heating/Cooling Return) OOther(explain under#21 Remarks) FROM ft. To ft DESCRIPTION(color,hardness,soillrock type,grain size,etc.
i2 OIL)
/4.Date Well(s)Completed: m Z Well ID# 17 3 ft. /Z ft 0 wiv SO i+
5a.Well Location: Z ft. .7 5- ft. AAA--
"0 l
z 5 rt 5 aft. 6 i2,A 6
Facility/Owne Name Facility ID#(if applicable) ft. ft.
ft
ft. r
Physical ddress,City,and Zip ft. 021
,
21.REMARKS,
County Parcel Identification No.(PIN) ,fr5r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) C� 22.Certification:
36 N ?�� d � y�g / Vy 8 - 6 -
6.Is(are)the well(s)• t F,-I>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: ❑Yes or nN'6-- 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-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: J (/--V (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3©206'and 2Q100')
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: Z--� (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter: (in.) 24b.For Injection 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,direct push etc.) county environmental health department of the county where installed
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) � I� Method of test: �0 G��
13b.Disinfection type: HTH Amount:gzArp1 6
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018