GW1-2021-05762_Well Construction - GW1_20211015

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Con a tor
Informatipn: l
�1�� ((// 14.WATER ZONES
Well Contra or Name FROM TO DESCRIPTION
Z
NC Well Contractor Certification Number 15.OUTER CASING for multi�awd wells OR LINER if a licable
Barnette Well Drilling,
Inc. FROM TO DIAMETER THICKNESS MAT IM
Company Name o It. I q0 ft i in. q �/
�
/ 16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: �! FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.) 4ft,
ft in•3.Well Use(check well use): ft.
Water Supply Well: t7.SCREENFROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public tt. ft. in.
❑Geothermal(Heating/Cooling Supply) iResidential Water Supply(single) ft. rt. in•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft- 4C ft- Cement/Sand Poured
❑Monitoring ❑Recovery ft. ft
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK Cifapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach,additional sheets if necessary)
% ft.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardn ss,soil/rock e, in size,etc.)
// ft
4.Date Well(s)Completed: �< 2 Well ID# 2 C2 ft. Z ft.
5a.Well LocAtion:
k,(,C �/OC¢ $ �/ 130 tt. rt
.
Facility/Owner
�Name
` Facilityft ft.
r ID#(i plic le)
� ft. ft !�..:•z =�;f
Physi ddress,City,and Zip ft ft.
2- j' 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one tat/long is sufficient) 22.Certific 'on: �.`• '`_.. i
2�, 716 1f N ISP617 W
2;�f C� /()///L..?_ -
6.Is(are)the well(s): IJPermanent or ❑Temporary Signa 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 ONo ISA 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 oJ'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: f 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �/ (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if diJjerent(example-3@206'and 2@1001
10.Static water level below to of casing:p (ft.) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
Information Processing Unit,1611 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
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 Rota 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health depaihnent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producin over 100,000 GPD: Copy to DWR,CCPCUA
/13a.Yield(gpm) Method of test: Permit Program, 1611 MSC,Raleigh I ,NC 27699-1611
[
13b.Disinfection type: HTH Amount: 1/2 Cup
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018