GW1-2021-02236_Well Construction - GW1_20210722

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Informa'on: ['
L ,
.Z 9 F7 11G# /V V 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
T`
? � - 2- fit• so ft Z a 6-4-1
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING foe "I cased wells OR'LINER Ira licable) -
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERLAL
ft. ft in.
Company Name
76;INNER CASING OR TUBING`,'eothermal closed,foo
2.Well Construction Permit#• 7 L._.7 G/"JJ/�v FROM TO DL4,METER THICKNESS MATERIAL
List all applicable well construction permits(:e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft in.
17.SCREEN.
Water Supply Well: FROM TO DIAMETER SLOT SIZE TRIMNESS MATERMLL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ItResidentiai 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: D rt. D rt. Cement/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL-PACK Cifapplicable).
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
El Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20'.DRILLING'LOG attach additional sheets.if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
O ft. Z 2> fL
4.Date Well(s)Completed: Well ID# U ft. ft.
5a.Well Location: ft. ft (`
ft ft j
Facility/Owner Name cif f� Facility #(if applicable) ft. ft. Err"f c,
Physical Address,City,and Zip !; / W" tv( ft ft. ?n„
21.REMARKS'
LL t
County Parcel Identi cationNo.(PIN) u�y''BjtO>1l�r�rt t
via J"`
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) p/ ( 22.C A' n:
` 27. 70 ��1�N ��uJC e 102� W
6.Is(are)the well(s): Permanent or ❑Temporary Si na o ertifie Well Contractor' Da
te
thff''rmation
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: es or ONO 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction 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 I 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.) 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@100') ;
10.Static water level below top of casing: C./ (ft.) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
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,NC 27699-1636
12.Well construction method: Air Rota 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
type:
`) Method of test: Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 2 " l Utl-1X/
13b.Disinfection I--ITI-i Amount: 1 IZ CUrl {
pk
Form GW-I North Carolina Department of Environmental Quality-Division of water Resources Revised 6-6-2018