GW1-2021-05630_Well Construction - GW1_20211015

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
���/V i -e G . �R,LL,`' 14.WATER ZONES I
FROM TO DESCRIPTION
Well Contractor Name
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3 7� A9 �[b�yft. i 1�?6 ft. 6
NC Well Contractor Certification Number 15.OUTER CASING for
ed wells ORLIINER f a liMM THCKNBarnette Well Drilling, Inc.C. FROM TO ETER RIAL
Company Name 6 ft 6-? fL *1 to
16.INNER-CASING OR TUBING geothermal closed-loop)
2.Well Construction Permit#: 2 D a z FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. i in.
3.Well Use(check well use): ft. fL in•
Water Supply Well: FR SCREENTO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) nResidential Water Supply(single) ft. ft. i�•
❑Industrial/Commercial ❑Residential Water Supply(shared) fig•GROUT
❑Irri ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Cj rt. 2-b rt. Cement/Sand Poured
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge El Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I 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)
FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
Q rt �- ft. V e- R b LL Gs-J
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4.Date Well(s)Completed: 2! Well ID# �2 "410z$ — ft. /s ft. 71t n.J 5, i2l/ t 5 i-/Jf
5a.Well Location: S ft. 6 � o 21.
/4i'n&f C�s /fv rtI�i�if+e�s 2�ft. Z c�drt' 6�!a
Facility/Owner Name Facility lD#(if applicable) ft. ft. ;•,. 1
o ft� L - ft.
Physical Address,City,and Zip f � ft. ft. 1
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21.REMARKS
7� r�I 62
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:
26 , /So7r0 N 7 g - L V5-3 7 W wU
6.Is(are)the well(s)• 'Onlermanent or ❑Temporary Signature of Certified Well Contractor Date
Bysigning this form,I herebv certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Dyes or >-- 1 SA NCAC 02C.0100 or]SA 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: Z ©a (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdiiferent(example-3@200'and 2@1001
s 24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: 'LS (ft.) Information Processing Unit,1617'!MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use
11.Borehole diameter: 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
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 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield Wm) Method of test:
Vkmsop
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13b.Disinfection type: HTH Amount: Q
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018