GW1-2021-00874_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
,Az E,®��, ]� 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
�� 7 6 9e ft /�a ft.
2/U ft. -A 2 a ft. 3 �I-/
NC Well Contractor Certification Number 15.OUTER CASING for multg-eased wells OR LINER if a licabte
Barnette Well Drilling, Inc. FROM TO DIAMETER THICIGNES3 MATERIAL
Company Name
t7 ft. IL / in. f�e_-2) ®V L
/ 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: `A. I/ r�G O ��
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 rt. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. rt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hTi ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: tt. ft. Cr6r:aAUS ad Poured
❑Monitoring ❑Recovery O ft. t}Q ft. Ciyf✓i 1
Injection Well:
rt. ft.
❑Aquifer Recharge ❑Groundwater Remediation
14.SAND/GRAVEL PACK d applicable)
❑Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessar
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
rt. � rt. b A,,.��o
4.Date Wel1(s)Completed. 2-/U -zi/ Well 1D# L(/,. 310 it- ZD ft e /I ry -rot-
Sa.Well Location: Q ft. -/ S fI t7 W.-
tt. art.
Facility/Owner Name Facility ID#(if applicable) ft. ft. e`
ft. ft �-� �' I V .�
ltJ D tJ ldiuti L61-
/
Physical Address,City,and Zip ft. ft.
c 21.REMARKS ,
k 1
County Parcel Identification No.(PIN) ^ Fay^t^•t^1 9fC`^,€r :Il. �Ig4i�
' � r° r`j(pil
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: DIV f 11`e
(if well/field,one tat/long is sufficient) 22.Certification:
D 3 Z t / N W
6.Is(are)the well(s)' gWermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well($)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Z-K0 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 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: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@206'and 2@100')
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: �-� (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: (in,) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(NC)
/�
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
13a.Yield(gpm) J
r Method of test: ���� Permit Program, 1611 MSC,Raleigh,NC 27699-1611
HTH
LI H / p
13b.Disinfection type: Amount:/� CU
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018