GW1-2021-02238_Well Construction - GW1_20210722 (2)

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
cyt px"6c'eq f4 LtJ 14.WATER ZONES .
Well Contractor Name FROM TO DESCRIPTTON
-75-ft. 9 a . It-
6 To ft. /00 ft. �-- %�! 15"a fts 1•
NC Well Contractor Certification Number 15.`OUTER CASING for Iti cased wells OR LINER tf a licable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICIGYESS MATERIAL
4 ft. 66 ft- 6/ in. sA P, 2 t !`�
Company Name
76.INNER CASING OR TUBING' eothermal closed-loop)
2.Well Construction Permit#: Q&9 J 7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) tt. tt. in.
3.Well Use(check well use): tt. ft. in.
Water Supply Well: 77.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ItResidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p 1L Z vft• Cement/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑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 fL fL
❑Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheets if necessa
FROM TO DESCRIPTION(color,hardness,soil/rock e, in size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
/ p 6 ft. 3 f- U e t2 L t-t.2-Q
4.Date Well(s)Completed: 6 /-Zl Well ID# 0 �3/ 7 3 ft' ft. E, �r
5a.Well Location: !o ft' 2 g ft' S �y
y to e 9-7 �l/`!G/�'I P C> i L� rt. j rr
Facility/Owner Name Facility ID#(if applicable) /�S-ft. / ft. O
6/S (A l p o l rl,vaJ /✓ _ It-
ft. ft.
F F-'
Physical Address,City,and Zip ft ft.
256o 9,rY-, 6v 21.REMARKS JUL
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .O r, essina VI11
(if well field,one lat/long is sufficient) 22.Certification fl J Se�ti on
6.Is(are)the well(s): AR-ermanent or ❑Temporary Signature of Certified Well Contractor' Date
Av signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or &N'o 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 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: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3Q200'and 2®100')
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: Z� (ftJ Information Processing Unit,1617I 'D
MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
f Borehole diameter: 6 (in.) 24b.For Injection Wells: Copy toWR,Underground Injection Control(NC)
Program, 1636 MSC,Raleigh,N627699-1636
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 deparhnent of the county where installed
r
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producin over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpm) ZT�u Method of test: CSiL�I�%�- �
13b.Disinfection type: u I n Amount: 1/Z Cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 6-6-2018