GW1-2021-02279_Well Construction - GW1_20210722

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1
1.Well Contractor Information:
(� /v N( Qfl Off u, 1 14.WATER ZONES
WeIlContractor Name FROM TO DESCRIPTION
haft. /!S ft.NC Well Well Contractor Certification Number '15.OUTER CASING for multi-cased
Barnette Well Drilling, Inc. FROM TO wells OR a LINER if licable
DIAMETER THICKGNESS MATERIAL
Company Name
d ft. �I in.
16.INNER CASING OR TUBING 'eothermal closed-loop).
2.Well Construction Permit#: J FROM To I 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): ft. ft. in.
Water Supply Well: iZ SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) IlResidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hTi ation ❑Wells> 100,000 GPD FROM I TO MATERUL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. 10 ft. Cement/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
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)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(co or,hardness,soiVrock type,grain size,etc.)
ft. ft. (M,( U.
ID ✓ f/`
4.Date Well(s)Completed: '/ -Z( Well # d I S rt. ft. a
5a.Well Location: ft. 4'
CIL4z& Leh e14 0���rs ILL) ft a BOG
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Physical ddress,City,and Zip
,Q�®�- �Q, 21.REMARKS
,l
County Parcel Identification No.(PIN)
In 01173 1Ui i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
-2-1 33 N 7,9 9'.dc' W Zr
6.Is(are)the well(s): gftfmanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or &Nlw- 15A NCAC 02C.0100 or 15A 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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ®r (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dii Brent(example-3@200'and 2@100')
z-S ft 24a. For All W Wells: Original form to.Division of Water Resources (DR),
10.Static water level below top of casing: ( ) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+/"
11.Borehole diameter: 6 (in,) 24b.For Injection Wells:Copy�to.DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air Rotary 24c.For Water Supply and Ope -Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct,pttsty etc.) county environmental health department of the county where installed
r ;
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) Z S Method of test: {// �1
13b.Disinfection type: H I n Amount: 1/2 Cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resourci s Revised 6-6-2018