GW1-2021-05590_Well Construction - GW1_20211015

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: [
1.Well Contractor Inf�ormation: / ,r
.11 At mot(: 40.t
14.WATER ZONES l
Well Contractor Name FROM TO DESCRIPTION
ft. l
Z��l�0 4- �S ft.
,
rt.
NC Well Contractor Certification Number �
Inc. 15.OUTER CASING for multi-cas d wells)OR LINER if a livable
Barnette Well Drilling, c FROM TO DIAMETER THICKNESS MA RL4L
ft. /
I ft.
t in. �.
Company Name
16.INNER CASING OR. ING. eothermal closed-loon)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC County,State, Variance,etc.) ft. I ft. I
3.Well Use(check well use): ft. I fL 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 TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: L� rt. Q rt. Cement/Sand Poured
❑Monitoring ❑Recovery fL fL
Injection Well:
rt. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK Q if applicablel,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL ft.
❑Experimental Technology ❑Subsidence Control et. 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 e, in sue,etc)
d 0 ft. v ft- ft ? vc k
4.Date Well(s)Completed: / Well ID# �U ft. fL
5a.Well
]Location- ft. ft. /
fL
Facility/Owner Name ft. ft.
Facility ID#(if applicable) �
2 O l6 31fa5 yn ft I ft.
Physical Address,City,and Zip ft. ft.
/ ( [ J
C. «-/ C 21.REMARKS \ 1 crii C i
County Parcel Identification No.(PIN) lt'Jst. '1r C��;;OY1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N 7�� 2S. Zi W �(
Jam ��• � z
6.Is(are)the well(s): #ermanent 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 QffNo ISA NCAC 02C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a copy
Ifthis 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: (ft.)
For multiple wells list all depths if dierent(example-3Qa 200'andd2@1001 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 7 V'' (ft.) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
Ifwater level is above casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) 24b.For Iniection Wells:Copy toDWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
.Well construction method:Air Rotary
(i.e.
Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
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 61ver 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) ?- Method of test: �+ Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1/2 Cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018