GW1-2021-05753_Well Construction - GW1_20211015

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
n /W/ tf- /o� 14.WATER ZONES
Well Contractor Name FRO TO DESCRIPTION
rt. �t i/X cat tr',g
NC Well Contractor Certification Number
15.OUTER CASING for multi cased wells OR LINER it a livable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name rt. ft f in. �� ? Cr
16.INNER CASING OR TUBING' eothermal closed-loon)
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) rt• ft. in.
3.Well Use(check well use): ft. fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICI4YESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) �dential 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&AMOUNT
Non-Water Supply Well: Q I'L .,a e.:> ft. Cement/Sand Poured
❑Monitoring ❑Recovery
Injection Well:
rt. rt.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK if applicable)
FROM TO I 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 it necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiltrock type,grain size,eta)
ft. ft. =.rc.p
4.Date Well(s)Completed: ' / Well ID# Q rt. �� ft `�4tog
5a.Well Location: ip ft. Z--r tt c
e?/IAA l' e ac i 23`ft. 96) 1 6' q
Facility/Owvnne�r Nammee7 Facility ID#(if applicable) ft. ft. _
�-
Physical Address,City,and Zip ft
-re P"S 21.REMARKS' -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lablonsufficient)
g is 22.Certification-
3 6- N Q TA W
6.Is(are)the well(s): ermanent 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 LiI'0� 1 SA NCAC 02C.0100 or ISA 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:
p� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �O � (ft.)
For multiple wells list all depths if different(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 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: b (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Rota I
(i.e.auger,rotary,cable,directpush,etc.) 24c.For Water Supply and Open!Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: Copy DWR,CCPCUA
24d.For Water Wells producing;over 100,000 GPD: Co to D
gh,
13a.Yield(gpm) �'1� Method of test: y���cri_t� Permit Program, 1611 MSC,Ralei NC 27699-1611
13b.Disinfection type: HTH Amount: 2 f ,
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources j Revised 6-6-2018