GW1-2021-02276_Well Construction - GW1_20210722

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: !
1.Well Contractor Information: j
14.WATER ZONES �
FROM TO DESCRIPTION
Well Contractor Name
�{ a ft. 1 J�D fL
JJ Zd �fl�+5ft. 1�16 IL
NC Well Contractor Certification Number IS.-OUTER CASING for multi-eased wells OR LINER if a licable
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
A ft. 62 "- in. fd�
Company Name c-
16.1NNER CASING OR TUBING etithermal closed-loop)
2.Well Construction Permit#: /OY FROM I TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) in
3.Well Use(check well use): ft. v ft. in.
Water Supply Well: 1F7R.S�CIREE 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
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. Z f] fI Cement/Sand Poured
❑Monitoring ❑Recovery ft. SD ft. i` ✓
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19,SAND/GRAVEL PACK if a' licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.'DRILLING LOG attach additional sheets if necessary)
Fz-
OM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
T' a rt. S- ft. � �',e� � - J
4.Date Well a21 s)Completed: Z'� Well ID# ft. 2 ft SQL
5a.Well Location: ft. ft. k
t61,9 koe z 6it. z z016
Facility/Owner Name Facility ID#(if applicable) ft. ft.
rI
Physical Address,City,and Zip
J v / ft. ft. o .,t
J, 'o a�
.1.1 21.REMARKS
County Parcel Identification No.(PIN)
cg1T1��viZlt
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees- ,, r
(i g ) 22.Certification: �i"1 vll�31" �Pr-ipp
tfwell field,one lat/lon is sufficient
N 78- 1?8A CFY w
6.Islam)the well(s): *permanent or ❑Temporary Signatures f Certified Well Contractor, Date
By signing this form,1 herebv certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or �i�o 1 SA NCAC 02C.0100 or I5A 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-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: Z Z-y Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2Q100')
24a. For All Wells: Original forin to.Division of Water Resources (DWR),
10.Static water level below top of casing: Zi✓ (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter: b (in,) 24b. For Injection Wells: Copy,to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produci>g over 100,000 GPD: Copy to DWR,CCPCUA
,r{
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Z� Method of test: 15/B'ev
13b.Disinfection type: r TH Amount: 1/2 Cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018