GW1-2021-05786_Well Construction - GW1_20211015

WELL CONSTRUCTION RECORD(GW 1
For Internal Use Only:
L Well Contractor Information:
i
®�g210, 14.WATER ZONES 1
Well Contractor Name FROM TO DESCRIPTION
( p ft. /� I
NC Well Contractor Certification Number �'�5 rt' S ft
Barnette Well Drilling, Inc. 15.OUTER CASING for multi iasedwells OR LINER ifa licable)
FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft- -t CJ ft /;� in. ���-21 .��
3®,A /L� 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: '�`^ .J FROM TO DLIMETER List all applicable well construction permits(i.e.UIC,County,State, Ym-iance,etc.) ft• ft in THICKNESS MATERIAL
3.Well Use(check well use): ft. ft in.
EIDIGeothermal
pply Well: 17.SCREEN
tural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Municipal/Public rt ft in.
(Heating/Cooling Supply) IlResidential Water Supply(single)
al/Commercial ft ft. in.
❑Residential Water Supply(shared)n 18.GROUT
❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft
❑Monitoring ❑Recove d Poured
FInjection Well: ry ft. ft. D ` L#
:1
er Recharge ❑Groundwater Remediationtt.er Storage and Recovery ❑Salinity Barrier 19-SAND/GRAVEL PACK if a licable
FROM TO MATERIALEMPLACEMENT METHOD
er Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control
ft. [t
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM To DESCRiPT10N(color,hardness,soil/rock t ype,grain size,etc.)
ft. ft
4.Date Well(s)Completed: '—1-Lf Well ID# J� �/�
5 ft. �• ft. !
Sa.Well Location: ft. d ft /
ft
Facility/Owner Name ` Facility ID#(if applicable) ft.
7�99
i� f 4��A�s�f�1..1 C• ft
Physical Address,City,and Zip (� � ft ft (�( 7
_� f Z /7 l T�_ 21.RENI.ARKS
County Parcel Identification No.(PIN) `: ^="''• ? '� t-t :�..
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
Q 1 7 ('� `� 22.Certification:
6.Is(are)the well(s): L—ermanent or ❑Temporary 4Sgnatu.-PC�enifi.d el)Contractor
Date
7.Is this a repair to an existing well ❑Yes Or BY signing this farm,I hereby certify that the well(s)was(were)constructed in accordance with
15A NCAC 01C.0100 or 15A NCAC 01C.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 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:
� d 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft)
For multiple wells list all depths ifdifferent(example-3@206'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: Z (ft) 24a. For All Wells: Original form;to.Division of Water Resources (DWR),
If water level is above casing,use + Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
12.Well construction method:
Air Rotary Program, 1636 MSC,Raleigh,NC 27699-1636
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells Copy to the
county environmental health department of the county where installed
[FOR WATER S:;typ�e:
:ffFl
LS ONLY: 24d.For Water Wells producing over 100 000 GPD Copy to DWR CCPCUA
Yield(gpm) Method of test: B Pernut Program, 1611 MSC, letgh,NC 27699-1611
Disinfection Amount:
s
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018