GW1-2021-02271_Well Construction - GW1_20210722

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WELL CONSTRUCTION RECORD (GW-1) 1 For Internal Use Only: !
1.Well Contractor Information:
14.WATER ZONES
WeIT Contractor Name FROM TO DESCRIPTION
1 15 Eft. /5:5, ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR LINER if a lieable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. �' ft. in. 5eAJZ,> V L.
Company Name VV
16.INNER CASING OR TUBING(geothermal closed400
2.Well Construction Permit#: / G z FROM I TO DL4METER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State, Variance,etc.) ft. It_ in•
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN ;
FROM TO DL4METER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) CJResidential Water Supply(single) IL ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft- CE Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft. i
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
El Aquifer Test ❑StormwaterDrainage ft. ft.
❑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,solltrock type, rain sue,etc.)ft. et. /l
C3 !e- �i
4.Date Well(s)Completed: Well ID# i ft. 1- fL " �,
5a.Well Location: ft. Z ft. �_
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ft. ft )
Ph ys II Address,City,and Zip ft. ft.
t4 �Jf /d-✓ f '� ,21.REMARKS
County Parcel Identification No.(PIN) Informcti
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �' '
(if well field,one lat/long is sufficient) 22.Certification:
3 4'•Y 7® N 7 Z S y3 W
�.�
6.Is(are)the well(s): rmanent or ❑Temporary Signa ure ofCertified 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 NN6" 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 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: 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@2000'and 2@100)
�✓ 24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,161 1 7 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: 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 producid;over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) t� Method of test:� 0/(� a
13b.Disinfection type: H I Tu n Amount: 'a
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources! Revised 6-6-2018