GW1-2021-05760_Well Construction - GW1_20211015

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
I.Well Contractor Information:
� I
14.WATER ZONES
Well Contractor Name FROM To DESCRIPTION
33 7,.K . l ®it. p,�it z
NC Well Contractor Certification Number (6 Z ft. / ��ft. Z l4
15.OUTER CASING for multi-cased wells)OR LINER tt a livable)
Barnette Well Drilling, Inc, FROM TO DIAMETER THICKNESS MATERIAL
Company Name o ft. 16 eft. 16 in. 5�� Z ��
16.INNER CASING OR TUBING "eothermal closed-loop)
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. fL in.
F
ter Supply Well: 17.SCREEN
gricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Municipal/Public ft. ft. in.
eothermal(Heating/Cooling Supply) IlResidenfial Water Supply(single)
ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
18.GROUT
Non-n-Waate
❑Non-Water
❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
r Supply Well: ft. 2cft• Cemeht/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK if a livable
MDRILLIG
MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer h additional sheets if necessar❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
a rt rt. 6 Lie 6 �
4.Date Well(s)Completed: 9"� Z Well ID# tt. ! ft 1
Trf iv
5a.Well Location: Z. ft. S// fL
/ 7T` fci C�R�/
V s� cl�C ri�,� fL c %C
Facility ZSwrier Nan Facility ID#(if applicable) ft.
ft. ft
Physical Addre s,City,and Zip ft. ft. ir)
�.'' G
wo
,rc_S 21.REMARKS
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.Certification
`I r9'7 N `T 1 j3.) -rip W
6.Is(are)the well(s): lermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certifv that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No 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 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 I 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: !6 (ft)
For multiple wells list all depths if different(example-3@200'and 2@1001 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: Z (ft) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
If water level is above casing,use"+" InformatiDn Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For In"jection Wells: Copy to DWR,Underground Injection Control(lUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air Rotary
(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:
24d.For Water Wells producinst over 100,000 GPD• Copy to DWR,CCPCUA
13a.Yield m ��G�Gt� Permit Program, 1611 MSC,Raleigh,NC 27699-1611
(gP ) z Method of test:
13b.Disinfection type: HTH Amount: 1/2 Cup
Form GW-t North Carolina Department of Environmental Quality-Division of Water Resources'j nA,,:�e P 4.4 In,o