GW1-2021-01067_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
NC W Contractor Certification A
Certification Number 7, ft v ft n 6"� /O�i�st3
15.OUTER CASING for multi-cased wells OR LINER if a livable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. `7 ft ` in. 1�R F plj
C
Company Name t� ✓osl +
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: 2-3 FROM TO DIAMETER I 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: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
[]Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. et. 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. -z-p ft. Cement/Sand Poured
❑Monitoring ❑Recovery ft ft
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if livable
❑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.)
ft. ft.
4.Date Well(s)Completed: /2-�D`20 Well ID# Z-� -3 ft. Y It.
e i 4 �
5a.Well Location: r g ft. �ft G 4� Srt D�1 f T
2 D L, 9!'� � �� // ��ft13 Dv ft. G t tn
Facility/Owner Name �^. Facility ID#(if applicable) tt. ft.
ft. " .7
Physical Address,City,and Zip ft ft.
21.REMARKS J
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - n
(if well field,one lat/long is sufficient) 22.Certification:
3 6 N 7 0 6-:5'1 wP 2 / z --30 2c�
6.Is(are)the well(s)• Mftrmanent 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 ®'Iqo 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a copy
IJ'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 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q206'and 2Q100�
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"++"
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
/�
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Ai r 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) f S Method of test: ��d�
HTH i�4 oz Ja
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018