GW1-2021-05632_Well Construction - GW1_20211015

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor
Contractor Information:
Vt Nitsi E �� �u�L�L
14.WATER ZONES I
FROM TO DESCRIPTION
Well Contractor Name
3 X 215 -7 ft. �O ra
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
D ft. 16 J ft * in-
Company Name r
(� 16.INNER CASING OR TUBING eothermal closed-loop)
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2.Well Construction Permit#: W 2- 1 CC 0 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: 1F7ROSM REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in,
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: rt. ft. CewAfl#Gaf4Poured
❑Monitoring ❑Recovery ft- ft
Injection Well:
ft, ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL 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,soillrock type,gmin size,etc.)
(� O ft "_ ft. P ILA C,
4.Date Well(s)Completed: (/ "31 Z( Well ID#W Z 1,1067K ft.
5a.Well Location: s--ft.
It.
C o A e•v Me_R er, -rf. 3�Sf- 6 o- c
Facility/Owner Name -! Facility ID#(if applicable) Q ft. ft
�/A re U & d,6Ae S/-�2P (\(�, ft. ft.
ft ft. . ' 4
Physical Address,City,and Zip ( a
:21.REMARKS
County o Parcel Identification No.(PIN) O�"
Sb.Latitude and longitude in degrees/min'
utes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification
N -2 17 � f) W
6.Is(are)the well(s) ermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this farm,I herebv certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or M�N-o 15A NCAC 02C.0100 or ISA 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: U 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: .3 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@I00D
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: Z (ft)
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
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11.Borehole diameter: CJ (in.) 24b.For Injection Wells: Copy to DWI,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
13a.Yield(gpm) -SI�Q 6 Method of test: I
13b.Disinfection type: HTH Amount: / ` -.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018