GW1-2021-02274_Well Construction - GW1_20210722

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Pi 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3 J �4�;�_ �%D ft. �Z GS
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a ticable
Barnette Well Drilling, Inc. FROM TO D METER THICKNESS MATERIAL
ft. ft ) c� in. iC���l rLIG✓
Company Name
16.INNER CASING OR TUBING 'eothermaiclosed=too
2.Well Construction Permit# z HI
r� FROM TO DIAMETER TCKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) +✓ ft• 81 ft E in. G
3.Well Use(check well use): ft. ft. in.
CA w
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TRICKINESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) C1Residential Water Supply(single) ft. ft.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT'
❑Irrigation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft Poured
❑Monitoring ❑Recovery ft.Injection Well: L�ft
ft.
❑Aquifer Recharge ❑Groundwater Remediation qo
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. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock e, ain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
ft. ft.
-70
4.Date Well(s)Completed: " 2 Well ID#� ft. ft `�c
5a.Well Location:
C,1 ,� Za f:3 ��!�• ft s"'t :-�- e
� r2/3
Facility/Owner N e Facility ID#(if applicable)" ft. rA i
ft. `f ft. � l,• 4
Physical Address,City,and Zipft ft. )�''U.,a..1 V r
160p,rQ�S��/t/ t 21.'REMARKS 'JUL
I
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 44 rSrnrAc;'nt, vi114
Ii�1 p,u '
(if well field,one lat/long is sufficient) 22.Certification: �tR 5E ,;On
6.Is(are)the well(s): 01'�� �� s
ermanent or ❑Temporary Sig cure of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Lilo' 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-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: CE) (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@I00')
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: z�� (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 27699-1636
12.Well construction method: Air Rotary 24c.For Water Supply and Opel-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 producin over 160,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of testl`E�L� Permit Program, 1611 MSC,Raleigh,NC 7699-1611
13b.Disinfection type: HTH Amount:
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources' ! Revised 6-6-2018