GW1-2021-02273_Well Construction - GW1_20210722

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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Well Contractor Name
NC Well Contractor Certification Number 15 OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Barnette Well Drilling, Inc.
ft. in.
Company Name 4 J c.rt
:16.INNER CASING OR TUBING eothermatcloseid-loo
2.Well Construction Permit#: / FROM TO DL4,METER 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 ft. ft. in.
❑Geothermal(Heating/Cooling Supply) CJResidential Water Supply(single) ft. fL in,
❑Industrial/Commercial ❑Residential Water Supply(shared)
78.GROUT .
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: �� ft- ��ft- Cement/Sand LAt/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PAC Of a lica6le
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
El Aquifer Test ❑Stormwater Drainage fL ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiltrock e, in size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2l Remarks)
LL /� ft. IL el de_' 4 f c��
4.Date Well(s)Completed: .T y Z-2% Well ID# A T ft. 'L �. 1 c
ft. ft. a
5a.Well Location- y emu -, ! i1+C�
S �� rt. G� rt 6''
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Z.5-C - od rai-&/2_5 G Z J�' ft. ft 1= 9 �
Physical Address,City,and Zip ft. ft.
y�C 0� 21.REMARKS 9 O
County I1t Parcel Identification No.(PIN)
Ilif0fri;3tiiCB ;-oce 1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long iiss�ssufficient) Q 22.Certification'
1
6.Is(are)the well(s): 1SPermanent or ❑Temporary Signature of Cer ntractor 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 nTTo- I5A 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 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 INSTRUCTIONS
9.Total well depth below land surface: G/ (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3@200'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, 1617 MSC,Raleigh,NC 27699-1617
lJ water level is above casing,use"+" i
11.Borehole diameter: 't (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 producin over 160,000 GPD: Copy to DWR,CCPCUA
lfJ Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: P AO K-;, ,
13b.Disinfection type: HTH Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of water Resources Revised 6-6-2018