GW1-2021-05758_Well Construction - GW1_20211015

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
�� /tom'�tiy tE3 �� � d fU p 14.WATER ZONES I
FROM TO DESCRIPTION
Well Contractor Name
q� ft.
3 �G ,�s ft. zs�ft z
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wel(s)OR LINER if a livable
Barnette Well Drilling, Inc. FROM TO DI4ViETER THICKNESS MATERIAL
Company Name t /4 rt. in. 5A P,7i r
16ANNER.CASING/OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: b/H, FROM TO DIAMETER 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 TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) I'Residential Water Supply(single) ft ft in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 718.GROUT "
❑Irri ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft- ®ft Cement/Sand Poured
❑Monitoring ❑Recovery
Injection Well:
rt. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft fL
❑Experimental Technology ❑Subsidence Control ft. ft
❑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,soil/rock type,gmin size,etc.)
O ft. ,- 8 z 6tc,12 A �
4.Date Well(s)Completed: -7 r Z Well ID# A s" It. Z Gj It.
0 sa c
5a.Well Location: L ft.
Jf/4-")?1;yGz t y 7 8 It-
Facility/Owner Na a Facility ID#(if applicable) ft. ft.
fL
Physical Address,Ci ,and Zip ft
�� 15 in zi::!� 21.REMARKS
County Parcel Ideentificatioonn No.(PIN) '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
�6 - Y5 �5 S N 72• 0 z 7 ?) W
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6.Is(are)the well(s): ermanent or ❑Temporary Sign ture of Certified Well Contractor Date
By signing this form,I hereby certifv that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ®'No' 15A 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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surfaced (ft.) Submit this GW-1 within 30 day of well completion per the following:
For multiple wells list all depths ifdierent(example-3@200'and 2@I00')
10.Static water level below top of casing: Z� 24a. For All Wells: Original form to.Division of Water Resources (DWR),
(ft.)
Information Processing Unit,1617iMSC,Raleigh,NC 27699-1617
If water level is above casing,use
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air Rotary
24c.For Water Supply and Operi-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 producml;over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) u� Method of test: O c1J
13b.Disinfection type: HT1�Tu Amount: 1/2 Cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018