GW1-2021-05742_Well Construction - GW1_20211015

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
_ I1.Well Contractor Information:
14.WATER ZONES C i
FROM TO DESCRIPTION
Well Contractor Name
NC Well Contractor Certification Number 15.OUTER CASING for mulfi cased wells OR LINER if a livable
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MApTERIAL
o it. r a ft in. 5&cc-zI / V
Company Name {� 16.INNER CASING OR TUBING 'eothermal closed400
2.Well Construction Permit#: v FROM To DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Countv,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) nResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
Oh-ri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C) ft- Z V ft- Cement/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK da livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage it. ft
❑Experimental Technology ❑Subsidence Control tt ft
❑Geothermal(Closed Loop) ❑Tracer 20,DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock e, in size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
,�j a it. j ft. 0 Uee4-
4.Date Well(s)Completed: /0 Z/ Well ID# J T 3 ft. /6 it 9 eA S d_l
5a.Well Location: ft. /i�r— ft. p Gc7�1 6 i J'
e A Y �� t�2s /�"Tt. 4[Z C IL
Facility/Owne Name Facility ID#(if applicable) ft. ft.
ft. ft.
Physical Address,City,and Zip ft.
21.AEMARKS
County Parcel Identification No.(PM)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3 Cl - Z N 00,—
6.Is(are)the well(s): anent 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 6f'�0 1 SA NCAC 02C.0100 or 1 SA 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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: d (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3@200'and 2@100')
24a. For All Wells: Original foim to.Division of Water Resources (DWR),
Ijwater level is above casing,use
f Static water level below top of casing: 5✓ (ft Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
"+" "
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
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
G 13a.Yield(gpm) 0 I� Method of test:
13b.Disinfection type: HTH Amount: 1 6 z"
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018