GW1-2021-02280_Well Construction - GW1_20210722

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: h
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
s- rt. Td tt.
12 5-ft. /-?,D rr
NC Well Contractor Certification Number '15.OUTER CASING for multi cased wells QR LINER if a licable
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
40 ft. fL in.
It
Company Name �� I Y
�` 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: 79 - f •! FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. % in.
3.Well Use(check well use): ft. fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL fL in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft. ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) iS.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 40 ft. �g-rt. Cement/Sand Poured
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19..SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑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,soil/rock e,grain size,etc.)
ft. 3 ft � O
/4.Date Well(s)Completed: ��2l Well ID# 3 ft• IL
5a.Well Location: a ft. / bft
9!96lf.. tz A e a l'U&J 2 S ft. fL
Facility/Owner N me Facility ID#(if applicable)
3J 11 y (,He RA ' ft. fL
Physical Address,City,and Zip
21.REbIAR1CS c
County Y` Parcel Identification No.(PIN)
li, iiCll r'Ct'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(ifwell field,one lattlong is sufficient) pr d 22.Certification: }.1 9-
9_OZ7��
6.Is(are)the well(s)• LPhlitanent 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 Mt"-- 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 I 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: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@I00')
(ft. mation 24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: ) Infor Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter: 0!� (in.) 24b.For Injection Wells:Copy t.DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1'636
12.Well construction method: Air Rota'1r/
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 producini over 100,000 GPD: Copy to DWR,CCPCUA
m Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gp ) J??�1 I 1 Method of test: lG t
13b.Disinfection type: HTU Amount: 1/2 Cup i
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources j Revised 6-6-2018