GW1-2021-02289_Well Construction - GW1_20210722

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: j 1
eo/V/1f`� tom/ 14.WATER ZONES
Well Contractor Name
FROM TO DESCRIPTION
35 ! (! ^ft. v ft I
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
d ft 66 ft 6 � . in.. S�/p.a I U
16.INNER CASING OR TUBING eothermal
Company Name 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. in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fr. ft. in.
❑Geothermal(Heating/Cooling Supply) (nResidential Water Supply(single) ft, ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hTi ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUW
Non-Water Supply Well: ft. 2 oft- Cement/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK Ufa livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING'LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
b LL to/
4.Date Well(s)Completed:,/fJ Well ID# ® ' 3 �- ft. 2,5 ft ;e CIA A b J'_
5a.Well Location: -z,.<-ft. Q ft. l'i>
tt. b^�tt
K �Ce/ve cln��o� fno
Facility/Owner Name Facility ID#(if applicable) :6 It.
2,it
rt. rt. R
Physical Address,City,and Zip
P.V-S6IL2 K 21.REMARK
t
County Parcel Identification No.(PIN)
nrn `sS111��Will
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification �Ci�u1�'3 E)1,;1'nrs
36 - 9-%S2-7 N - `? �3'? W
6.Is(are)the well(s)• *P014manent or ❑Temporary Signature of Certified Well Contractor Date
By signing this farm,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ItNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
IJ'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: Q (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2®100D
24a. For All Wells: Original form to.Division of Water Resources (DWR),
ff Static water level below top of casing: Z- S� (ft•) Information Processing Unit,161 MSC,Raleigh,NC 27699-1617
IJ'water level is above casing,use"+/"
11.Borehole diameter: (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 f
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,d¢ect.push etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produci�over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-161 l
13a.Yield(gpm) Method of test: g✓/v f
13b.Disinfection type: H 1T H Amount: 19 10 0
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018