GW1-2021-05747_Well Construction - GW1_20211015

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
It
• 14.WATER ZONES 1
Well Contractor Name FROM TO DESCRIPTION
3? 7 d_ j rt. r 3 5 k. k 1
NC Well Contractor Certification Number
ft. r
15.OUTER CASING for multi-cased wells OR LINER(if a livable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS I MATERIAL
Company Name ft. G ft.
ji 16.INNER CASING OR TUBING? eothermal closed-goo (/
2.Well Construction Permit#; ( FROM TO I 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: 1'7.SCREEN
❑A CnitUral FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑MunicipaL/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single)
in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
1&GROUT
❑ n- anon ❑Wells> 100,000GPD FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: 0 rt. o rt. Cement/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑A uifer Recharge rt• ft.
q g ❑Groundwater Remediation
❑Aquifer Storage and Recovery19.SAND/GRAVEL PACT: if a livable
❑Salinity Barrier 71DRILLING
TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage I't.
❑Experimental Technology ❑Subsidence Control ft.
❑Geothermal(Closed Loop) ❑Tracer LOG attach.additional sheets if necessar❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
Y ft. �. ft.
4.Date Well(s)Completed: `/ yZ� well ID# ft. ReA e�f s,
Sa.Well Location: Zsft. Lf,IC'rt, ����� Z,®�
��/�Zryt y �41t✓tL'L`iy5- 1.© (� 't1�S ft. 7 s- ft.
Facility/Owner&ame Facility ID#(if applicable) "7�Tt• /6 6 ft.
�Cl.lvc� e22/, 4C4- 6 rt. rt.
Physical Addre /City,and Zip ft. ft.
7� 01
A,' _
21.REMARKS'..
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.Certification:
3;? N 7?_ y23•z1 w
6.Is(are)the w -ll(s): "ermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby verb that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 19Pt6 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
IJ'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:
j / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 6 6 d (fL)
For multiple wells list all depths ifdifferent(example-3@200'and 2@100� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: �, (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 to DWR,Underground Injection Control(TUC)
Air Rota Program, 1636 MSC,Raleigh,NC 27699-1636
i..Well construction method: 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• Co
[� Permit Program, PY to DWR, CCPCUA
13a.Yield(gpm) —5 D Method of test BC ✓C'CX m, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amonnt: 1/2 Cup t
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018