GW1-2021-05609_Well Construction - GW1_20211015

WELL CUNSTRUCTIOIN RECORD (GW-1) I For Internal Use Only:
1.Well Conti ctor Infor'Y_
n:
i f1P la.WATER ZONES [ ;
FROM TO DESCRIPTION
Well Cont ctorName�j f
ft. 1 L C ft. 2 I
/ �/rt. t X, rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable)
Barnette Well Drilling, Inc. FROM TO DIAM TER THICKNESS MATERIAL
ft. L`f✓ft. in. (19
Company Name v v
2 16.INNER CASING OR TUBING eothermal closed-loon)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. 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) Oesidential Water Supply(single) ft. ft. I 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: G ft. Oft Cemert/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a tieable
❑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.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
ft. Z ft Ate G
4.Date Well(s)Completed: L� `'/Well ID# 2U rt. Q� ft ' wL
ft.
Sa.Well Location: ft.
14 ft cC�/ J/ )
-F— /t � l� !// . ft.
Facility/Ownel1r��Name Facility ID#(if applicable)
ft. ft. ",�''��y +
Physical/A,ddress, ity,and Zip
ft
21 ft.
.REMARKS _ ria�,i•
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.Certif ation:
pp��
7 z z
6.Is(are)the well(s): Arermanent or ❑Temporary 1pature of Certified Well Contractor Da
\\ 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 9 rp 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 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: / ,mil 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: l y (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)
�D ) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
If water level is above casing,use
f Static water level below top of casing: (ft. Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
"+' "
11.Borehole diameter: 6 (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air Rota 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: 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