GW1-2021-02290_Well Construction - GW1_20210722

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information:
40
e 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
-33 A6 � 2•Gsft. -raft. lit-,I
Z'D ft. � 7�r' Z` �
NC Well Contractor Certification Number 15.OUTER CASING for m ulti-cased wells OR-LINER trap licable -
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
A ft. 6�g ! in.
Company Name V
/) `16.INNER CASING OR TUBING' eothermal 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. fL in.
Water Supply Well: .17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential 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: ft. ft Gemea 8nd
❑Monitoring ❑Recovery ft. G
Injection Well: ft. ft.
Ave A
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL I 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,soillrock type,grain size,etc.)
L v ft. ft.
4.Date Well(s)Completed: 6/f'zJ Well ID# v �' ft. f Z it. �& Ce
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5a.Well Location: j� �/ Zft. Is ft. 19 C..
2 i-a ) A s !1 c/o r/<d It. fL O C
Facility/ wner Name Facility ID#(if
applicable) _!';_ft' - 0 V++
44 t cdz e) 4L
G
Physical ft. ft.
�lAAddress,City,and Zip (��(� a
f J K C 6 �Jl/ / / 21:REMARKS
J f-"' O
County Parcel Identification No.(PIN) ` 2021
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one ladlong is sufficient iivll i-'1'OL3•'' ' I` `
) _ 22.Certification: Ip3�L'ttf3
-39 N 7� ` 1b_: 9 W '
Ro,72_1� � G 13A2,1
6.Is(are)the well(s): manent or ❑Temporary Signature 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 L'PN0 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
®9.Total well depth below land surface: —ft) Submit this GW-1 within 30 da�s of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100) Y p p g'
10.Static water level below top of casing: z s 24a. For All Wells: Original tprm to.Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: Copyjto DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air Rotary24c.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 160,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Permit Program, 1611 MSC,Raleigh,
NC 27699-1611
2—� �
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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