GW1-2021-02262_Well Construction - GW1_20210722

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
�6 f 14.WATER ZONES f
Well Contractor Name �FROM TO DESCRIPTION
- b ft. 6,0 v fa Viz+ k I
�3 ft. 2 +eft. ;d`ga
NC Well Contractor Certification Number 15.OUTER CASING(for! wells QR.LINER if a licable
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 ft. G ft 6/�� in. 7 1 ee
/J 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: 1H, FROM TO DUMETER 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 fL ft. in.
❑Geothermal(Heating/Cooling Supply) I'Residential Water Supply(single) ft. R. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 11- Zo ft oured
❑Monitoring ❑Recovery ft. 'L
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
,19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑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/rock type,grain size,etc.)
D rt. �- rt v e X/=. a
4.Date Well(s)Completed:Ja O7 Well ID# 7 tt 2-Z ft & f`
5a.Well Location: ft. ft. w D d
ft. 6l a tt.
Facility/Owner Name Facility ID#(if applicable) ft.
ft. it.
Physical Address,City,and Zip ft. ft.
S oN 7b 31.REMARKSi JUL
County Parcel Identification No.(PIN) cg 1
l3t.}o1 C'rooe..
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '6oIIY'.
(if well field,one lat/long is sufficient) 22.Certification:
3S- 3Z N Z8` A339 W i 3 -17 ~zl°
6.Is(are)the well(s)• 041-1,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 vfb 15A NCAC 02C.0100 or 15A NCAC 0,2C.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: r 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 dierent(example-3 t@20b'and 2®100')
24a. For All Wells: Original form to.Division of Water Resources (DWR),
If Static water level below top of casing: Z 5 (ft.) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
/f water level is above casing,use"+"
11.Borehole diameter: (in.) 24b.For Iniection Wells: Copylto DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:AI r 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
13a.Yield(gpm) Method of test: Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: Z
Form GW-I North Carolina Department of Environmental Quality-Division of Water R
esourcesi Revised 6-6-2018
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