GW1-2021-00877_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
p14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 95-
ft. Q 0 ft. /j lo/
�3;�/9 376 R. -3 !It AAA
NC Well Contractor Certification Number 15.OUTER CASING for multl cased wells OR LINER if a lieable
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
O ft. �6 ft. 6 in. SdR 2J
Company Name 16.INNER CASING OR TUBING(eothermal closed-loop)
2.Well Construction Permit#: FROM TO 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): tt. ft. in.
Water Supply Well: FROMREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. 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 I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: rt. ft. Cement/Sand Poured
❑Monitoring ❑Recovery
Injection Well:
❑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(color,hardness,soil/rock type,grain size,etc.)
o ft. ft. o u e R 6 a
oz
4.Date Well(s)Completed: Z -3,2/ Well ID# 152 3 14
ft. /Z ft. y S.O/t
5a.Well Location: Z �jQ ft. R Q
ft. 1?0 c�
Facility/Owner Name Facility ID#(if applicable) ft. ft.
/O 9 L fib ft. ft. ^'V=LJ
Physical Address,City,and Zip ft. ft.
C&1 O J 21.REMARKS
County Parcel Identification No.(PIN)
. information Processing
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: DWR GeE&P
(ifwell field,one lat/long is sufficient) c� 22.Certification:
3� e2 2• 3�► N 7 f - l 9 W
6.Is(are)the well(s)• Wle'rmanent 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: Dyes or MKo /5A 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 ofthe oJ'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-3@200'and 2@1001
Z ft 24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b. For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air 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 producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 2LQ5
Method of test: { j�
13b.Disinfection type: HTH Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018