GW1-2021-02265_Well Construction - GW1_20210722

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
j 4 V,-f 14.WATER ZONES i
Well Contractor Name
® FROM TO DESCRIPTION i
NC Well Contractor Certification Number V
15.OUTER CASING for multi-eased webs)MINER if a iicablel
Barnette Well Drilling, Inc. FROM TO DIAMETER THICwVE'5s MATERIAL
ft. G 2 ft ( in,
k d9 a� G
Company Name a+""16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft, ft. in
❑Geothermal(Heating/Cooling Supply) nResidential Water Supply(single) It. fL
❑Industrial/Commercial ❑Residential Water Supply(shared) 17S GROUT
❑lrri ation ❑Welts}I00,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: © ft. Z.F3 fr- Cement/Sand Poured
❑Monitoring ❑Recovery fL ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK da 'ticable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control it. fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG Winch additional sheets if necessary)
❑Geothermal{FleatingtCooling Return} ❑Other(explain under#2 t Remarks} FROM To DESCRIPTION(color,hardness,soiitrock in skae etc
J t� 16 ft. ft. 0 a A. 6?.� -1,AJ
4.Date Well(s)Completed: F J" Z Well ID#� � t � it. /0 ft.
5a.Well Location: a tt. ft dig d t
6& _Ll�e �i�/`�C�'- tl y �Q ft tt t6 Q
Facility/Owner Name Facility ID#(if applicable) It. ft.
e �-
w� �A . fL ft- y �.� ' �F�
Physical Address,City,and Zip ft. ft.
c
'g f't s o/L) 21.REMARKS jut °s
County Parcel Identification No.(PIN) Unil
56.Latitude and longitude in degrees/mirtuteslseconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
6.Is(are)the well(s): tRI(ermanent or ❑Temporary Signafur-FtTCeftified Well Contractor. Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or M?qo- 1 SA 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 I GW-I 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: 4
166 (ft.) Submit this GW-1 within 30 days of well,completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2 r@1001 j
24a. For Ali Wells: Original fond to.Division of Water Resources (DWR),
10.Static water level below top of casing: 5 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy jto,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 100.000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) � Method of test /� i
HTH -6 . I
13b.Disinfection type: Amount:
I 3
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resoure s ! j Revised 6-6-201 R