GW1-2021-05591_Well Construction - GW1_20211015

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
J
10,y I /< u t 14.WATER ZONES
e FROM TO DESCRIPTION
Well Contractor Name j ft. ft v A /'�. C � �-
ft. ft I
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased:wells OR LINER-if a licable
Barnette Well Drilling Inc. FROM TO DIAMETER THICKNNESS MATERIAL
ft. /j 6 IL / in.
t
Company Name ,
16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: S�� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State. Variance,etc.) i in.
3.Well Use(check well use): ft. ft 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
❑Irrigation ❑Wells> 100,000 GPD, FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. -c-ntt Cement/Sand Poured
❑Monitoring ❑Recovery ft. ft
Injection Well:
ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable).
❑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.'DRILL-ING LOG attach additional sheets if necessary)
so
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness, iltrock e,grain size,etc.)
4.Date Well(s)Completed: -Z - , Well ID# %� ft f ft
5a.Well Location:
C ft 7 oft is t
Facility/Owner Nam Facility ID#(if applicable) ft. ft.
/I t '
1XC,U1d L!2/�l� /�6LG tPf� cS ft. ft.
Physical Address,City,and Zip ft ft. 6
C2�2 21.REMARKS J
County Parcel Identification No.(PIN) r oagll 9 unil
_t;.,� ..rfi�Q1 .,..�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: „.. r E�Ccc
(if well field,one lat/long is sufficient) 22.Certification �;�wR"uCiw
36- zG s�5't-6 r N Z ' " i c, 4 35 W
6.Is(are)the well(s)•ltnermanent 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 tNW- 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the oJ`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 wi:11 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-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: 706 (ft.) Submit this GW-1 within 30 days of well completion per the following-
For multiple wells list all depths if different(example-3Q200'and 2@100)
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: Z (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) 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,directpush,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY
LWELLS ONLY: / 24d.For Water Wells Producink over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) .,I- Method of test: ow _ Permit Program, 1611 MSC,Raleiigh,NC 27699-1611
u u 1
13b.Disinfection type: HTH Amount: I/2 Cup kl
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018