GW1-2021-02278_Well Construction - GW1_20210722

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information: ,Q
R6A2A19; e
14.WATER ZONES ;
Well Contractor Name FROM I TO DESCRIPTION
3 3 �6 R //,5--ft. I Z 6 IL 3 ` " t
2 /,5-ft. ft. 7
NC Well Contractor Certification Number Inc. .15.OUTER CASING'for T!L1 ased wells Og LINIER if a licable-
Barnette Well Drilling, C FROM TO DIAMETER THICKNESS MATERIAL
ft. ` L fL /� in. S 2 z I t/<
Company Name V v V
`J p 1.6.INNER CASING OR TUBING eotherma!clos¢d-loo
2.Well Construction Permit#: � / / FROM TO DIAMETER THICKNESS MATERLA-L
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. tt. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERW EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft p fL Cement/Sand Poured
❑Monitoring ❑Recovery ft. fL
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
❑Aquifer Test ❑Stormwater Drainage 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,soit/rock type,grain size,etc.)
rt. ef. O v
4.Date Well(s)Completed: �-��'2.1 Well ID# 7 ft. 6 ft' t
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5a.Wet[Location: t7 ft. Is- ft.
Mu C,6Ck e I jt:ee f5 81J _9-'L 3 D D`L jF.r,/+y
Facility/Owner Name Facility ID#(if applicable) ft. ft. F-
ft
t.t_s,�- 1P Pin R-eg-
Physical Address,City,and Zip
U 2 21.REMARKS ie
County Parcel Identification No.(PIN) 1jlZlt
i s c;II660t '� n
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
3 . 28 s 3 N 7g • w At"_� .!: Z d Z
6.Is(are)the well(s): nfWffianent or ❑Temporary Signature of Certified Well Contractor 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 MIN - 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
IJ'this 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.
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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 I 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: ©Q (ft.) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths if different(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: ZJ� (ft.) Information Processing Unit,16 11 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+-
24b. For Injection Wells: Copy,to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AI r Rotary24c.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 100,000 GPD: Copy to DWR,CCPCUA
/ Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) ZZ? 1 Method of test: !g cU
13b.Disinfection type: HTH Amount:V5,966P
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources F Revised 6-6-2018