GW1-2021-05589_Well Construction - GW1_20211015

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATERZONES I
'v-Well Cont FROM TO DESCRIPTION
ractor Name
3 � 4 3 rt. '� t. I J41
it. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased.wells OR LfNER if a livable)
Barnette Well Drilling Inc. FROM TO DIAMETER THICKNESS MATERIAL
t ft-
Company � f$ in. / Fele
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: J 7 FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. `r in. 1' -�J 1 J
3.Well Use(check well use): ft. ft. in. �7 G v C_
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public It. fL in.
OGeothermal(Heating/Cooling Supply) ©Residential Water Supply(single) ft. ft. lit•
Dlndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. poured
❑Monitoring DRecovery It-
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStomnwaterDrainage ft. ft.
DExperimental Technology DSubsidence Control ft. ft.
DGeothetmal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) OOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardne`soittrock e,grain size,etc)
Q ft. It.
• "�S
ell
4.Date Well(s)Completed: ?-ZI-F-1 Well ID# zo +�'/ ft. ft
5a.Well Location: 5-ft. _r q e5 A fe
6fif A J eR y'ft. p b ft /'�
Facility/Owner Name Facility ID#(if applicable) ft. ft.
l -5 R. ft. ft. �s r l 6
f (0 t 15 e rz> J�--1 `"'
Physical Address,City,and Zip / �1 q ft.' ft.
c r�L.li2�' 11 / 7' Q f l 21.REM RKS
County Parcel Identification No.(PTN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: y;tr C or 4in
(if well field,one lat/long is sufficient) 22.Certification:
7T d ear(6 W -
6.Is(are)the well(s): "ermanent or OTemporary 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 IJNo 15A NCAC 02C.0100 or 15A 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:
&.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-I 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.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100)
10.Static water level below top of casing: Z.✓ {ft) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
a If Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
water level above casing,use op
11.Borehole diameter: (in.) 24b.For Injection Wells: Copy to'DWR,Underground Injection Control(TUC)
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 fiver 100,000 GPD: Copy to DWR CCPCUA
L!13a.Yield(gpm) Method of test: /tl I'{fle Permit Program, 1611 MSC,Raleigh,NC 27699-1611
7`'"� �y
13b.Disinfection type: HTH Amount: a
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018