GW1-2021-02267_Well Construction - GW1_20210722

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3 3 '7 ft. //0 ft. J26 J4
NC Well ContraCt�Certi ion Number Sc>ft /w rL d ��
'15.OUTER CASING for multi-ccssi d hells)OR LINER it a licable
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MAATERUL
Company Name V
T ft. 6 2-ft. 6 * in. 5A 2-z (
�j /� 16.INNER'CASING OR TUBING eothermat closed-loop)
2.Well Construction Permit#: �7 T Z FROM TO DIAMETER TMCICNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State, variance,etc.) ft. f, j in.
3.Well Use(check well use): ft. ft. tn.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TMCKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) I] Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I8:GROUT
❑1rri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: rt. Z rL Cement/Sand Poured
❑Monitoring ❑Recovery
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. fL
❑Geothermal(Closed Loop) ❑Tracer 26.DRILLING.LOG attach additional.sbeets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM_. TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
a ft. S ft- 6 a b" ke-)
4.Date Well(s)Completed:/ -Z f Well ID# /T 7�?� \j rt• `o ft. h
5a.Well Location: b ft ZS ft O a I e-
k"- 91Y9,6 k 1 e- 1,0,-` Z 6S ZS ft. 3S ft 62 /z/gy o ,e
Facility/Owner Name Facility ID#(if applicable) 3-5-
ft- Z 2 dt• c lS
56VA.�B®a� 1 / f0tc EeP-J� �L5 ft. fL
Physical Address,City,and Zip ft. ft G�I
21.REMARKS20
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County Parcel Identification No.(PIN) J U L
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: roc ' t, Q'Ilt
(if well field,one lattlong is sufficient) fl aL1�ry�T�jeci;on
22.Certification:
3 6 - 7- W 9 N -79 . 19/6-Z.3 W el"r, ' 3-9 -z>
6.Is(are)the well(s)• &Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,[hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MP]O✓ 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
1f 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-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 INSTRUCTI6NS
9.Total well depth below land surface: Z Z D (ft.)
For multiple wells list all depths ifdii different(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: 7i e✓ (ft. Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+/" f
11.Borehole diameter: [7 (in.) 24b.For Injection Wells: Copy 4to jDWR Underground Injection Control(NC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction 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 producinl over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 6 Method of test �J��[� Permit Program, 1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: HTH Amount: <�
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018
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