GW1-2021-02228_Well Construction - GW1_20210722

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
ea A r�/�i r �1�LL_ 14.WATER ZONES t,
Well Contractor Name FROM TO DESCRIPTION
3,3 7t3 -Iq 3
s-rt. 6o ft .Z. 7 ,q
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a livable
Barnette Well Drillings Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name
D ft. ft 6 in. -$*"ZI
-7 L,t, 16.-17VNER CASING OR TUBING eothermalclosed-loo
2.Well Construction Permit#: 4 l O � 53 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. fL in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
[]Agricultural ❑Municipal/Public tt. ft. in.
❑Geothermal(Heating/Cooling Supply) Kesidential Water Supply(single) ft. rt. 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. Z O rt. Cement/Sand Poured
[]Monitoring ❑Recovery ft. et
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 14_SAND/GRAVEL PACK(if applicable)icable
❑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,soil/rack type,gnin size,etc.)
ft. ft. e-p 6 LkQ
4.Date Well(s)Completed: Z' -/�~2/ well ID# 'Z SA0 34 OU _j ft. S- ft C I-1 So `
5a.Well Location: ft. j' ft. A DAP
8l c / u��Z;t ','ela ss-ft. /8v It. G d l�
Facility/Owner Name Facility ID#(if applicable) ft. ft. e
'1 O 6 41-0 wit E// tjV l�.r d- ft. ft. �,,,,L� , >m
Physical Address,,City,and 9Zip Q ® ? ft. ft. 2021
P LL X/7/7Iy/ / G ( J 2 21.REMARKS
County Parcel Identification No.(PIN) processing Unit
otion
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
D�'L'trZ Se
(if well field,one lat/long is sufficient) p 22.Certification:
N �o �� W
6.Is(are)the well(s)• Alrermanent or ❑Temporary Signature of Certified Well Contractor' Date
By signing this form,I herebv certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MW-5 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 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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: y� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: w (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@206'and 2@100')
24a. For All Wells: Original forth to.Division of Water Resources (DWR),
10.Static water level below top of casing: 7- (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells: Co
11.Borehole diameter: (in.) py to jDWR Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 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 ofjthe county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 160,000 GPD: Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh;NC 2l7699-1611
13a.Yield(gpm) 6��- Method of test': �<dc.t, ' i
0 4
13b.Disinfection type: HTH Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resourc es Revised 6-6-2018