GW1-2021-00520_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
3 3 7 6 s ft. fv v ft. .g
4�srt. rt ,q 3 J U t 0.Pxio /,rx(a
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
FROM TO DIAMETER THICKNESS MATERIAL
Barnette Well Drilling, Inc.
Company Name 0ft. 6ft l� in. -2 ' U C
16.INNER CASING OR TUBING eother at closed400
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 ft. ft. in.
❑Geothermal(Heating/Cooling Supply) [!]Residential Water Supply(single) ft. ft. 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: ft. Ze- Cement/Sand Poured
❑Monitoring ❑Recovery fL fL
Injection Well:
ft. ft.
❑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.)
�}} aft. - ft. e U_ae(a
4.Date Well(s)Completed: / -/ �Z Well ID# /(✓ S- ft. Zz ft. eA- C l�
5a.Well Location: Zz ft. ft.
v 39 ft. OQ ft K
Facility/Owner Name Facility ID#(if applicable) ft. ft.
�p
fd !c S- 614_�SS �� - ft. ft
Physical Address,City,and Zip ft. ft. r -
2021
21.REMARKS r
County /V Parcel Identification No.(PIN) ,'•,•� y, `;rl 1, }��i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ` u
(if well field,one lat/long is sufficient) 22.Certification:
3 6 - L 6 2-5'6 N -7 . 0 3X z z. W
6.Is(are)the well(s): immanent 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 MX5 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I' 00 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3Q206'and 2@100)
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: ZS (ft.) 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
13a.Yield(gpm) 3 Method of test: 'e �/a�
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: H I uTu n Amount: Wap
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018