GW1-2021-02287_Well Construction - GW1_20210722 (2)

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Co actor I for 'on:
� �� ( /� � � 14.WATER.ZONES '
Well Contractor Name
� FROM TO DESCRIPTION
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`7 V�-1 ft 1 ZS rt 2 6 6
NC Well Contractor Certification Number Inc. 15.OUTER CASING for multi cased wells OR LINER if a licable)
Barnette Well Drilling, c FROM TO DiAM R THICKNESSMAFTERIAL
D ft. � ft Y in. 0A 2 /
Company Name ,( `f 1
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: /I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in,
❑Geothermal(Heating/Cooling Supply) MV esidential Water Supply(single) fL 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: ft. 2-V ft- Cemeht/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
El 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 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 type,grain size,eta)
? rt. �U ft. � �Jv� u
4.Date Well(s)Completed: / ! z Well ID# Z Z.C) ft. job fL G ,
5a.Well Location: 0ft. �v ft
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Jle �2 D A-
Facility/Owner
ft ft.
Facility/Owner Name Facility ID (if ap(ficable) ft. ft. a+-
S if 7o k 10 K vP 0 ft fL L_
Phys' at Address,City,and Zip -� L-cc fL ft. I C
eh VG Z 21.REMARKS
C unty Parcel Identification No.(PIN) processing I�1ZIt
n�vl vE i;0n
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) ^� 22.Ce 'IC on
6 a V4 N ! q 7 l W Z
6.Is(are)the well(s): dPermanent or ❑Temporary SigSature of Certifie Well Contractor] Date
Bysigning this form,!hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 11No 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-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
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9.Total well depth below land surface: / ! (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3®200'and 2@100)
10.Static water level below top of casing: D (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"+
11.Borehole diameter: (in,) 24b.For Injection Wells: Copylto[DWR Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
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12.Well construction method: i 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 producin over 100,000 GPD: Copy to DWR,CCPCUA
2-6 /© e j Permit Program, 1611 MSC,Raleigh,NC 27699-1 61 1
13a.Yield(gpm) Method of test: t
13b.Disinfection type: HTH Amount: 1/2 Cup '
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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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