GW1-2021-02263_Well Construction - GW1_20210722

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
i
1.Well Contractor nformation- P
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
zNl� 2 A _ ,� ft. �� ft.
ft. ft.
NC Well Contractor Certification Number -.15.OUTER CASING for multi-cased wells)OR LINER tf a livable)
Barnette Well Drilling, Inc. FROM TU DiAi�IETER THICKNESS MATERIAL
Company Name O .� O `� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: J FROM I To DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e,UIC,County,State, Variance,etc.) ft. I ft. in.
3.Well Use(check well use): ft. I fL
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Aesidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑bTi ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft- Cement/Sand Poured
❑Monitoring ❑Recovery
Injection Well: ft tt.
❑Aquifer Recharge ❑Groundwater Remediation
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. fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,gr2in size,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
1 Z7i tt. I�1- ft. 0 J
4.Date Well(s)Completed: ? l Well ID# !! ft. 3.o/ ft. 0
5a.Well Location: 1F ? ft. f 3 ft. f ,9 c-L
U-6 f r C n i(. g-, 12-� v IL -77 ® C
Facility/Owner Name Eactility W#(if applica e) it. ft.
s 14 cD ; L t�(' /sty° fL tt p� U
Physical Address,City,and Zip
ft ft. t�—
a
County Parcel Identification No.(PIN)
nr CC�SIt1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlon is sufficient
C g ) 22. rti anon: �
( 0 1.573-Q N 5 W
I
6.Is(are)the well(s): InPermanent or ❑Temporary Si nature of ertified Well Contractor D e
By signing this form.!hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing welt: ❑Yes or J1No 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 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 ifnecessary.
drilled: / ' 7 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-3@200'and 2@100')
24a. For All Wells: Original form to.'Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program, 1636 MSC,Raleigh,NC 27699-11636
12.Well construction method: AI r 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
{ I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producinlgover 100,000 GPD: Copy to DWR CCPCUA
��/D (� Permit Program, 1611 MSC,Raleigh,NCi27699-1611
13a.Yield(gpm) Method of test:
1�TL1 0�1 �z�', n
13b.Disinfection type: H 1 n Amount: f%' f'
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018