GW1-2021-00523_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
/lQOn/�j �p L�' &LA_ & 14.WATER ZONES
ii�" FROM TO DESCRIPTION
Well Contractor Name
f-0 ft.
1 tt. 'iZ R I4 r
33 ft. �t30 rL Ay-% G 0,
NC Well Contractor Certification Number 15.OUTER CASING for mo1=sed wells)OR LINER if applicable
FROM ro DIAMETER THICKNESS MATERIAL
Barnette Well Drilling, Inc.
ft. � fL
Company Name
1-6.INNER CASING OR TUBING . eothermal closed-loop)
2.Well Construction Permit#: 1Y 73�d FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Countv,State, Variance,etc.) ft. fL 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) [IResidential Water Supply(single) fL tt. 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: O ft- 2- Cement/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
tt. 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. fL
❑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. 5- rt- 0 v ,btd-.eAcnao
4.Date Well(s)Completed: ' Z /Well ED# 7.3e -5- C/R
5a.Well Location: ft. �,,pp�
Facility/Owner Name Facility ID#(if applicable) ft. ft. q•, l'
ft. ft.
Physical Address,City,and Zip ft ft.
21.REMARKS
County Parcel Identification No.(PIN) Y-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat(lon{g�is
sufficient) p 22.Certification:
�� K:J�� •E . �. / iy
6.Is(are)the well(s)• tiermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,[hereby certify that the well(s)was(were)constructed in accordance with
7.IS this a repair to an existing well: ❑Yes or LR1Vo I SA 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 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 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: �^ 24.SUBMITTAL INSTRUCTIONS
J 9.Total well depth below land surface: e-® (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3@200'and 2@100')
24a. For All Wells: Original form to.Division of Water Resources (DWR),
If Static water level below top of casing: s (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
44 /�®e Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) ✓ Method of test: �/l(2��
13b.Disinfection type: H 1 T1�n Amount: �S eI S
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018