GW1-2021-02223_Well Construction - GW1_20210722

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: �.}.
14.WATER ZONES '
r FROM TO DESCRIPTION
Well Contractor Name
3.3 zG
NC Well Contractor Certification Number 15.OUTER CASING'for multi cased wells)OR LINER' if a licable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICICNESS MATERUL
O ft. �: IL in.
Company Name i
{� Q 16.:INNER CASING OR TUBING.(geothermal closed-loop)
2.Well Construction Permit#: /® ✓ 2 y FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. U1C,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. [t. in.
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft. it. in.
❑Geothermal(Heating/Cooling Supply) nResidential Water Supply(single) rt. rt. i�•
❑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- GemehtS t� Poured
❑Monitoring ❑Recovery ft. o ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control
❑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,grain size,etc.)
p O ft. ft.
4.Date Well(s)Completed: 'LS'2(Well ID# `�d ZO 6 ft. 2- 7- ft- sQ�
5a.Well Location: Z ft. Q o
72P r o/osaeo G, 0 7 &6,6C_1C
Facilityility/Own Facility ID#(if applicable) ft. ft.
Physical Address,City,and Zip
cod 1 ` 17
2T.REMARKS..
County Parcel Identification No.(PIN)
3,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
30/. -1'I 2.�3 D N �2• Z 7 q- Tog W
6.Is(are)the well(s)• 19ermanent 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 0 1 SA NCAC 02C.0100 or 1 SA 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: ® (ft.) s of well:completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@I00) Submit this GW-1 within 30 day i
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: (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)
p Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:~i r Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,directpush,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
13a.Yield(gpm) Method of test: ! Gy b _J Permit Program, 1611 MSC,Raleigh,NC 27699-1611
� 1�
13b.Disinfection type: HTFi Amount: urw -7 If
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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