GW1-2021-00526_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 ft. ft.
� � � s
3 a � �-�
ZeSit. z4a ft'
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
() ft. ft 6 in. .5a r? r PVC
Company Name
�� 16.INNER CASING OR TUBING eothermat closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. WC,,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FR SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public rt. tt. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) g ft, 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: ft. Z eft Cement/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well: it. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery El 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,soillrock type,grain size,etc)
,�,���� ft. ft.
4.Date Well(s)Completed: Z_ZS &;)Well ID# / / �`' rt. ft.
Sa.Well Location: T rt. 3S' ft. A-) SD,
5 O ft O AAs'oIv'C
Facility/Owner Name Facility ID#(if applicable) 60 D 36b ft.
ft. ft. vim, y eJ�l��T s� ��J�`7 fo�. 17ZZ�',Ir�f �,�L�/`'� �Ul I c-^ "�'i:�,f "•,.7 �',1-%t
Physical dress,City,and Zip ft. ft.
�� 21.REMARKS
v_ / / ` v
County Parcel Identification No.(PIN) -•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N 79 - X 7 -a t w
yyue9- Z 2 ,5 8 r
6.Is(are)the well(s) ,.anent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing welt: ❑Yes or &?M- 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
1f this is a repair,fill out known well construction information and explain the nature of the q/'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: J (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'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
4r water level is above casing,use
11.Borehole diameter: (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
/� p 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) Method of test: krY Permit Program, 1611 MSC,Raleigh,NC 27699-1611
(-�
13b.Disinfection type: HTH Ao ant:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources /R,vised 6-6-2018