GW1-2021-02268_Well Construction - GW1_20210722

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
FROM TO DESCRIPTION i
Well Contractor Name 26 ft. 010 ft. AL &a
6 5> ft. 160 ft. A 3F?'.S'fc�Qo tom, I
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if o linable
Barnette Well Drilling, Inc. FROM TO DL4METER THICKNESS MATERIAL
Cs ft. 18,3 ft 6 4� I
in. 156-(/ 2-1 A/C
Company Name -lo V 76.INNER CASING OR TUBING' eothermabclosed-loo
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2.Well Construction Permit#: FROM I TO I DIAMETER THICKNESS IMATERIAL.
List all applicable well construction permits(i.e.UIC,County,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 ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) 35fre-sidential Water Supply(single) tt. ft. lit•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water supply Well: ft- Zd ft- Cement/Sand Poured
❑Monitoring ❑Recovery
Injection Well:
ft. tt.
❑Aquifer Recharge ❑Groundwater Remediation
d9.SAND/GRAVEL PACK Cifapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
ft. ft O /Lo- &Cs_
4.Date Well(s)Completed: �O 2.� Well ID# / v ft. / Z ft
5a.Well Location: ft. 3-57 t t le
S ierJ eey
Facility/Owner Name Facility ID#(if applicable)
p �
C ©S,5 0/� � ! 7 J ft. ft. G E 1 E U
Physical Address,City,and 1Zip ft ft.
Q-S DiJ Q o 21.REMARKS
CJ �
County Parcel Identification No.(PIN)
Inforri ation Pm>;OS
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r
(if well field,,one
lat/long is sufficient) p 22.Certification:6- 7L 7 (S N -7 W `
6.Is(are)the well(s)• LtiPermanent or ❑Temporary Signature of Certified Well Contract Date
By signing this form,I herebv certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or LKo 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 ojthis 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: ( ) i
For multiple wells list all depths if dii ferenr(example-3@200'an�@1001 f t Submit this GW-1 within 30 days of well completion per the following:
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10.Static water level below top of casing: (ft.) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells: Copylto'DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air Rotary 24c.For Water Supply and Ope I n-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,duect.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
,y6w Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) ZT-.0 Method of test: �V j p
13b.Disinfection type: HTH Amount: 1 ��
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 6-6-2018
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