GW1-2021-02277_Well Construction - GW1_20210722

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: E
1.Well Contractor Information:
Ul(1 ly,'y e e i5l eg lY l 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
Z ZD ft. Z fL
I /
7
NC Well Contractor Certification Number 15..OUTER CASING for multi-cased wells OR LINER if a licable)
Barnette Well Drilling, Inc. FRO M TO OL4METER THICI4�iESS V MATERIAL
/
Company Name
ft. ft. 6 in. S�vIZ'LI C
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/ 96.INNER CASING OR TUBIYG(geothermal closed-loo
2.Well Construction Permit#: FROM I TO DIAMETER 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 MATERL4L
❑Agricultural ❑Municipal/Public tt. ft. in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft. ft.
❑Tndustrial/Commercial ❑Residential Water Supply(shared) 88.GROUT
❑Irrigation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft, 7,P pfL 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 ft. fL
❑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,soiltrock type,grain size,etc.)
o ft. ft e 4 L,U_ �
4.Date Well(s)Completed: 7 J ZI Well ID# /7 / ft. ft e C
ft. fL < D
5a.Well Location:,(l e t, �I o Q S
a _5 ft. /i fL 6de,6 K
Facilit/Kwner Narne ,I , Facility ID#(if applicable) it. TT ft.
Physica Address,City,and Zip ft. ft.
21.REMARKS .a
County I�•� Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell/field,one lat(long is sufficient) Q� 22.Certification:
N < V ' Z W (�
6.Is(are)the well(s)• [%Pe im_anent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I herebv certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Mhlfo 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 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-I 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: 7"`®o (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')
10.Static water level below top of casing: ZS (ft.) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
if water level 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 construction method: Ai r Rotary 24c.For Water Supply and Op in-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 over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) < Method of test: Permit Program, 1611 MSC,Raleigh,NC 27699-161 i
L�I u j
13b.Disinfection type: HTH Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources! Revised 6-6-2018
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