GW1-2021-05761_Well Construction - GW1_20211015

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information: /� I
t�/q-v^' / � `l= 14.WATER ZONES I
Well Contractor Name FROM TO DESCREMON
ft
NC Well Contractor Certification Number ft. f jQ ft. i /S
15.OUTER CASING for multi-cased wells OR LINER if a liable)
Barnette Well Drilling, Inc. FROM To DIAMETER THICKNESS MATERIAL
Company Name 6
ft. 62fL in. e•���1 �C
[� 16.INNER CASING OR TUBING(geothermal closed400
2.Well Construction Permit#: _ ` FROM To DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U1C,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) MResidential Water Supply(single) ft. ft. in.
❑Industrial/Cornmercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ;.,-!n ft- Cement/Sand Poured
❑Monitoring ❑Recovery ft. fL
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
19.SAND/GRAVEL PACK(if applicable)
❑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 ft TO DESCRIPTION(color,hardness,soilfrock a in size,etc.)
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n It- Ui/R.btu(t CXQ
4.Date Well(s)Completed: f©�•�"�/ Weil 1D# T7 ft. ft. e
Sa Well Location: ft. ft. !� tit r Hoyle
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c' n2 J,4 JPDx ID�c� g ft. © , 6 c� � J
Facility/Owner Name Facility ID#(if applicable) ft. ft.
_fir✓ESI�>o "7L96.0 uil(� Zlr ft
Physical Address,City,and Zip a ft tt. Y
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: s"`
(if well field one IaVlong is sufficient) 22.Certifia n: `'
2A N 7ie" RCS 1-96 W
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6.Is(are)the well(s): Mr-manent or ❑Temporary SiPAEredT Certified Well ontract Dar
By signing this form,I herebv certify that ithe well(s)was(were)constructed in ccordance with
7.Is this a repair to an existing well: ❑Yes or MNv-- ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
1f 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 omier.
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: ! (ft.)
For multiple wells list all depths if dii erent(example-3@206'and 1@100) Submit this GW-1 within 30 days Of well completion per the following:
25 24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: (fL) Information Processing Unit,1617 MSC Raleigh,NC 27699-1617
If water level is above casing,use"+" g g >
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 producing;over ver 100,000 GPD: Copy to DWR,CCPCUA
(� Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) b Method of test: ��D t�11Pt�-
13b.Disinfection type: HTH Amount: 1/2 Cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources' Revised 6-6-2018