GW1-2021-02225_Well Construction - GW1_20210722

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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_ J�/� e e i /` ( 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3 �6-� s ft.
d ft. C9 1
NC Well Contractor Certification Number �tJ ft. 160 ft 431-M i
15.OUTER CASING for multi-cased wells)OR LINER if a ticable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
® ft. j"L 11. % in. 5 _ 1 ��C
Company Name 7 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: 139 j FROM I TO I DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,Countv,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 ❑MunicipaVPublic rt. it. in.
❑Geothermal(Heating/Cooling Supply) dResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUYr
Non-Water Supply Well: ft- Z6 fL Cement/Sand Poured
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK d 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)
❑Geothermal FROM TO DESCRIPTION(color,hardness,soiltrack e, in size,etc.)
(Heating/Cooling Return) ❑Other(explain under#2] Remarks) 0 ft. .j ft. e�b L>- Q 'nI
4.Date Well(s)Completed: /-� Well ID# It. /1? It.
t 4ky., lUGL c
ft. ft d ,r e
Sa.Well Location "�,,�
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Physical Address,City,and Zip f, ft. f�
c 21.REMARKS ,t
County ! Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 4t 11 '
(ifwell field,one]at/long is sufficient) 22.Certification IanJ „w�j Jr
6.Is(are)the well(s): &ftrmanent 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 &NO 15A NCAC 01C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a copy
IJ'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 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: ZDt (ft.)For multiple wells list all depths Submit this GW-1 within 30 days of well completion per the following:
if diJjerent(example-3@200'and 2@100')
10.Static water level below top of casing: (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: 9 (in.) 24b.For Injection Wells: Copy;to;DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Ai r Rotary
24c.For Water Supply and Ope i-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 producin;over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program, 1611 MSC,Raleighi NC 27699-1611
�L�d Q-
13b.Disinfection type: H I H Amount: 1` 7 o
it
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018