GW1-2021-05744_Well Construction - GW1_20211015

WELL CONSTRUCTION RECORD GW-1
For Internal Use Only:
1.Well Contractor Information:p
14.WATER ZONES f
Well Contractor Name FROM TO DESCRIPTION
NC Well Contractor Certification Number p Z rt 38S{t r p+
Barnette Well Drilling, Inc.
15•OUTER CASING(formulHcesedwells ORLINER Ifs licable)
FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft. {{ ,
6 y in.
2.Well Construction Permit# 16.INNER CASING OR TUBING eothermal closed-Ioo
�; FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. {t in.
3.Well Use(check well use): ft. ft in
Water Supply Well: 17.SCREEN
❑Agricultural ❑Municipal/Public FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Geothermal(Heating/Cooling Supply) [!]Residential Water Supply(single) ft. ft. in.
01ndustrial/COmmercial fL ft j-in.
❑Residential Water Supply(shared)
❑hTi ation 18.GROUT
❑Wel1S> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
❑Monitoring O ft. r)JU,` rG Cement/Sand Poured
tio ❑Recovery ft. G ft.Injecn Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL PLAC
❑Aquifer Test ❑Stoimwater Drainage ft. {t, EM EMENT METHOD
❑Experimental Technology ❑Subsidence Control
ft. ft.
❑Geothermal(Closed Loop) ❑Tracer
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRH'T ION(color,hardness,soiurock ----rai--
ftetc.)
- ft © ii e t2
4.Date Well(s)Completed: Well ID# 7 3 ft 6 {t
5a.Well Location: � o I' ft. Z 5 ft.Irk He- ft-
�
Facility/Owne Name Facility ID#(if applicable) ft• ft. 7tg
Physical Address,City,and Zip ft ft
ee k_5 �� Z 1 21.REMARKS J
County ! >'i'i mk
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient)
2 3��2 Z N 22.Certification:
cation:
�� .. �/ �®�8
6.Is(are)the well(s): MKIr-lanent or ❑Temporary Signature of Certified Well Contractor -� L U ���'�•!
Date
thisflm, fv that the well )was(were)constructed in
7.Is this a repair to an existing well: ❑Yes or 8No BSAtNCAC 02C.0100 orreby 15AcNCAC 02C.0200(Well Const coon Standardsaand that a cwith
opy
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 ivell 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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional
drilled: pages ifnecessary.
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:_ �0 � (ft.)
For multiple wells list all depths ifdii ferent(example-3Q200'and 2@100� Submit this GW-I within 30 days of well completion per the following:
10.Static water level below top of casing: ZS (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 tok 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
FOR WATER SUPPLY WELLS ONLY:
county environmental health dep i ent of the county where installed
rL. 24d.For Water Wells producing over 100 000 GPD• Copy to DWR,CCPCUA
13a.Yield(gpm) 36 Method of test: /Q ',Q Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection e; HTH l�v
tyP Amount
A
Form GW-t North Carolina Department of Environmental Quality-Division of Water Resnumes