GW1-2021-05746_Well Construction - GW1_20211015

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
I.Well Contractor Information:` , 41}
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
?�„ Il a rt. l Z art S f
NC Well Contractor Certification Number 2.4-fit• Z�
15.OUTER CASING for multi-cased wells OR LINER'if a licable
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 6' ft. 6 ft. 6 Fj in. d t LAG
16.INNER CASING ORTUBING' eothermalclosed-10o )2.Well Construction Permit#: Z 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
❑A cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
� ❑Municipal/Public ft. ft.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single)
ft.
❑IndustriaUConunercial ❑Residential Water Supply(shared)
❑Irri ation I&GROUT
❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft• � rt. Cement/Sand Poured
❑Monitoring ❑Recovery ft It.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation rt. ft.
❑Aquifer Storage and Recovery19.SAND/GRAVEL PACK 1f applicable
❑Salinity Barrier FROM TO MATERIAL
❑Aquifer Test ❑S EMPLACEMENT METHOD
tormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft, ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional'sheets it necessar
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I
FROM TO DESCRIPTION(color,hardness,soiVrock e, rain size,etc.)
C� rL
4.Date Well(s)Completed: / —✓7-2 )Well ID# �" ft. j s fL
� S -
Sa.Well Location: Jr ft. �s. ft. ,
OI�r-, e=� - -rt. 2 ft. 6�
— �A�•-(k��s l.
Facility«/Owner Name Facility ID#(if applicable) ft. ft.
ft
F r 'n 1
Physical Address,City,and Zip ;,, ft
21.REMARKS
County Parcel Ideentification No.(PIN) T J
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaVlong is sufficient) •.'.,-. ,
�- Z$ _ 22.Certification:
ff-5 N 7-d . -Y '.�' W �
6.Is(are)the well(s): ermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I herekv certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 9M 15A NCAC 02C.0100 or 15A NCAC 01C.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-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: 14-
For multiple wells list all depths ifdii ferent(example-3@200'and 2@I00) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: Z r (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
11.Borehole diameter:�__(in.) 24b.For Injectiion Wells: Copy to IDWR,Underground Injection Control(IUC)
12.Well construction method: Rotary Air Rota Program, 1636 MSC,Raleigh,NC 27699-1636
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells Copy to the
FOR WATER SUPPLY WELLS ONLY:
county environmental health department of the county where installed
24d.For Water Wells Droducinsr o ier 100,000 GPD• Copy to DWR CCPCUA
13a.Yield(gpm) � Method of test: fp(y Permit Program, 1611 MSC,Raleigh,�NC 27699-1611
�
13b.Disinfection type: HTH Amount: (zpp 6
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018