GW1-2021-02270_Well Construction - GW1_20210722

1 .
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: f
1.Well Contractor Information: i
6?6)v,v .14.WATER ZONES I'
Well Contractor Name FROM TO DESCRIPTION
1 r 0 ft. 6C�0 ft. 2-fC A 1
p -h::� l 7 - lU�
NC Well Contractor Certification Number 15.OUTER CASING for mulfi cased wells OR LINER if a licable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name V ft. 1 6 Z ft. G in. SA_e Z1 rJ/
Z 16.INNER CASING OR TUBING'eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits i.e.UIC,County,State, Variance,etc.) ft. ft °'
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft. ft. in•
❑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. ft. Cement/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation '
19:SAND/GRAVEL PACK da licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control
❑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 type,gmin size,etc)
D ft. ft. 2 &.-
q
4.Date Well(s)Completed: 3 /'.Z Well m# -a- ft. ft C //9
5a.Well Location: ?_ ft. ft. S S 4,
�. K Lo f Z8Z 3 5-ft. /Xo u
Facility/Owner Name T Facility ID#(if applicable) It. ft.
�C�u..�I,[�o�� it. ft. a
Physical Address,City,and Ziip1 fL ft. I
„.r J 5® =A
re�d Jy 2_ [� 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1rifnrmationProcessing Unit
tfwell field,one lat/lon is sufficient U,1,Section
(� g ) 22.Certification:
6.Is(are)the well(s): anent or ❑Temporary Signature of Certified Well Contractor 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 MWe- 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
ifthis 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: / p 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: !0 0 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths iftliferent(example-3@200'and 2®100')
10.Static water level below top of casing: Z (ft.) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static
a above casing,use op Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If i
11.Borehole diameter: C4 (in.) 24b. For Injection Wells: Copylto'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) ��I Method of test: .6 L� f
13b.Disinfection type: HTH Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resourcles! Revised 6-6-2018