GW1-2021-02220_Well Construction - GW1_20210722

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
f9yLV,1,,/ P. 24.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
FF//�� /3s ft. p ft. -?,A.,w
NC Well Z-1 Certification Number I zO ft ryZ�t ��,�;� 3003y® �DO
15.OUTER CASING for multi cased wells OR LINER if a livable)
Barnette Well Drilling, Inc. FROM TO D{ANIETER THICKNESS MATERIAL
ft. ft. I ' in.
Company Name
,/ , d `16.1NNER CASING OR TUBING(geothermal closed-loop)-
2.Well Construction Permit#: f 7 7 FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) 0 ft. O ft.
3.Well Use(check well use): ft. ft. in•
17.SCREEN
Water Supply Well:
pP y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidentiai Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation ❑Wells> 100,000 GPD, FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft- Cemm4rY%nd Poured
❑Monitoring ❑Recovery ft. 2 a ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.'SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLIN'G LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
D ft. 3 fL D vc-f,?-f aLt t2 A 0 u�
4.Date Well(s)Completed: 19 -Z Z'z(Well ID#--/'Y- 7,Z f// 3p `
5a.Well Location: /Z ft. 6-
An JP 69,ILsc�,fi Lo v fipa It. gmv
c
Facility/Owner Name Facility ID#(if applicable) `
O� 61 f�//lS��� ft. ft.
N.
7 / e�
Physical Address,City,and Zip ft ft.
l
21 REMARKS
UNA
County Parcel Identification No.(PIN) 3^iil�'3i14I1 Jf f'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) G 22.Certification:
36- � 7(j/? 7- N ! / rO t'X, W pD
6.Is(are)the well(s): !W rmanent or ❑Temporary Signature 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 MKNo` 15A 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 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
T,�.
9.Total well depth below land surface: O® (ft.)
For multiple wells list all depths if different(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells: Copylto DWR,Underground Injection Control(IUC)
11.Borehole diameter: 16 (in.) Program, 1636 MSC,Raleigh, I NG 27699-1636
12.Well construction method: AI r Rotary24c.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 producin over 100,000 GPD: Copy to DWR,CCPCUA
�® Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) �0 Method of test:ewf
13b.Disinfection type: uTu Amount: IZ C U p
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources! Revised 6-6-2018
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