GW1-2021-02266_Well Construction - GW1_20210722

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: !
1.Well Contractor Information:
OAPA-Ai l? f.Pt W-1A 724 14.WATER ZONES 1
RIPT
Well Contractor Name FROM TO DESC ION
3-r,z" 2.4ce.It. Z.Sa ft. Zc r_I 7
bait. aft. 2��(
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells)OR LINER if a licable)
Barnette Well Drilling, Inc. FROM TO DU
THICKNESS MATERIAL
2 V i t�+
Company Name O
�� 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICI4�IESS MATERIAL
List all applicable well construction permits(r.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑Tndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrri ation ❑Wells>100,000 GPD FROM TO MATERML EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 'Z Oft- Cement/Sand Poured
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if appi icable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology OSubsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer 20.DRELLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soilfrock e, in size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) `
b ft. it. o t c 6 QG O.,v
r ft
4.Date Well(s)Completed: Z I Well ID# r7 ft. / J e O ,-
S ft. 7� ft
5a.Well Location: !
a a�Q 7 ft. i d
SN� 6
V oo t. �
$ C.i
Facility/Owner Name Facility ID#(if applicable) fL ft.
ft. W ft
/l9 �R�1 Le>��So�� 1-N• .�..
ft
Physical Address,City,and Zip jut
ft. r tD
&zS O'_ / !® 21.REMARKS,�
County �/ Parcel Identification No.(PIN) SStCi. UtZll
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 56 V t,OD
(if well field,one lat/long is sufficient) p 22.Certification:
3 Z d 2.-7 N 7� r A0 _W ,p r
6.Is(are)the well(s): flftrmanent or ❑Temporary Signature of Certified Well Contractof 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 MLN&-- 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 ofthis 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) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if d fferent(example-3Qa 200'and 2@100')
24a. For All Wells: Original I 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(TUC)
Program, 1636 MSC,Raleigh,NC'27699-1636
12.Well constriction 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 producing overf100,000 GPD: Copy to DWR,CCPCUA
,�? 0"o Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) � Method of test: f(�E � ,' �
u u
&- Z i
13b.Disinfection type: HTH Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018