GW1-2021-00538_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Q IJA/ . 2�� / 14.WATER ZONES
Contractor Name FROM TO DESCRIPTION
Well Cont
3 5 7( �3 D ft. If- ft 2�,or -
I- Z At A
NC Well Contractor Certification Number 15.OUTER CASING for multitased wells OR LINER if a licable
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name V
A ft. 1 'ZIt. G _�, in. C�f�e-e vL
16.INNER CASING OR TUBING eother al closed-loop)
2.Well Construction Permit#: 19(1E FROM TO I 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. rt. in.
Water Supply Well: 17.SCREEN
FROM 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
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. rL CERTer1 .remd•Poured
❑Monitoring ❑Recovery 0 ft ". e 2
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 ❑StormwaterDrainage 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 e, rain size,etc.)
O ft �c ft. d v le fC,b 4 F2
4.Date Well(s)Completed:1-�S Z 0 Well ID# /1 / ft �g rt' )
I�
Sa.Well Location: 55c) G t ` T7J
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Oe e4;7e. 41 ft. ft.
Physical Address,City,and Zip diu Af- ft. ft. '• %'
rip- a� Z63 21.REMARKS
'v
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iablong is sufficient) 22.Certification:
36 -Y_s?8'S N 7 T• a ?6.U W ie oyz t� • �. 1 -/5 z
6.Is(are)the well(s): lllPermanent 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: Oyes or 0 o 1 SA 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: 3 `C-V (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')
r 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(IUC)
/�
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) 16 Method of test: A,910a 1 Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: �Cup ��
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018