GW1-2021-02222_Well Construction - GW1_20210722

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information: i
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
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NC Well Contractor Certification Number ,15.OUTER CASING for multi aced wells OR LINER if a lie' ble)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft. I gb ft j in. SA R2 1 C/C
..16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: h'G L� FROM TO I DIAMETER I 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: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) CJResidential 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: ft. ft- Gawamtea"Poured
❑Monitoring ❑Recovery ft. ft' � `;.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery El Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
El Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if neeessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc.)
/ ft. ft
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4.Date Well(s)Completed: "-4? 2,) Well ID# G� ft. Z ft.
5a.Well Location: `3 �{ �S-ft. .5—ft.
// /�`���J� S ft. Z 2 ft !�L
Facility/O er Name Facility ID#(if applicable) ft. ft 7
Physical Address,City,and Zip ft %
3 l/ 21.REMARKS �).
County Parcel Identification No.(PIN) on
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: D it v
(if well field,one tat/long is sufficient) 22.Certification: v ti
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6.Is(are)the well(s)• LWermanent or ❑Temporary Signature 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 MW 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
9.Total well depth below land surface: 2- (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100')
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: 5 (ft.) Information Processing Unit,1617 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,NCI 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 producin over 100,000 GPD: Copy to DWR,CCPCUA
ff y Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) �G) Method of test: 1G�jai G� j
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13b.Disinfection type: HTH Amount: 1/Z CUP ;
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources' Revised 6-6-2018
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