GW1-2021-05606_Well Construction - GW1_20211015

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information:
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92 /I/d1'L PIC V_i ' 14.WATER ZONES I a
FROM TO DESCRIPTION
Well Contractor Name 13 Oft. 1 9S ft. 1 3 �y
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NC Well Contractor Certification Number `��t. / �� ft. 1 . Z �15.OUTER CASING for mu)ti ca§eddwe�lls))OR LINER if a livable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft. 6 r, m.
7g 2 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: / C FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County,State, variance,etc.) ft. fL 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) ItResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT a
❑Irrigation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. fL Cama4uganA Poured
❑Monitoring ❑Recovery D tt. 36 tt. J9ou­s+,fv)
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. fL
❑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,s il/rock type,grain size,etc.)
b tt. ft. buLA LtN
4.Date Well(s)Completed:a Z Well ID# ft.
�Q f 4
5a.Well/Location: Z ft. 2 T tt. R L LuiaLj Q
! !0,& nn a kq ell Ndm 2 �ft. fL
Facility/Owner Name Facility ID#(if applicable)
3 s" f y�C4 ✓2�/l+- G� ll�'f�Its S � _ ft ft
Physical Address,City,and
Zip fL
9-41 le)29 21:•REMARKS
County Parcel Identification No.(PIN) a,r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/Iong is sufficient) (i 22.Certification:
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• Q� ! L N c� f 4 LtF-� W O ►O7Lc.r.� Gam. v/G /!� S <`�'"�
6.Is(are)the well(s): 941e'rmanent 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 0 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 I 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: 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')
Static water level below top of casing: 2 5^ (ft.) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
10. Information Processing Unit,1617,MSC,Raleigh,NC 27699-1617
If 10.waterStatic
level is above casing,use op
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Rotary�7�/
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
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Z� t� Method of test: b
13b.Disinfection type: HTH Amount: 1/2 Cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018