GW1-2021-02281_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: -
14.'WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Barnette Well Drilling Inc. mom To DNMETER !THICKNESS MATERIAL
r ft. � � ft 6 t' in. 5'M Z J 2 `
Company Name
7Z 16.,INNER CASING OR TUBING 'eothermal closed-loop) -
2.Well Construction Permit#' / OJ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,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) OResidential Water Supply(single) ft. ft. ��•
❑Industrial/Commercial ❑Residential Water Supply(shared) is.GROUT
❑Irri ation ❑Wells> 100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ftPoured
OMonitoring ❑Recove ft. ft. �r
Injection Well: ry v �
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable . '
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage it ft.
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets.if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft ,r- ft. e %1L 4-W-)
4.Date Well(s)Completed: 3 "L Z -ei Well ID# J- ft. 2. 1.
t' ft. es S
ft.
Sa.Well Location: (
it i eld�t t:�frary �.,c, tt. t ft `
Facility/Owner Name Facility ID#(if applicable) ft. ft.
le
ft. ft.
Physical Address,City,and Zip ft ft. E
21.REMARKS O
County Parcel Identification No.(PIN)
..f.�*r". g'i0111 f^.LE'S5ing
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) c� 22.Certification' ��
6.Is(are)the well(s)' aPermanent 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 VW6' 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 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: 3 o o (ft)
For multiple wells list all depths if dierent(example-3Q200'and 2®100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: e (ft.) 24a. For All W
Wells: Original form to.Division of Water Resources (DR),
If water level above casing,use op Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: Q. (in.) 24b. For Injection Wells: Copy Ito DWR Underground Injection Control(TUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air 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 ofthe county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producini;otver 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleih,NC 27699-1611
13a.Yield(gpm) / f� Method of test: ��L4r.� j
13b.Disinfection type: HTn Amount: �°`P" gj
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources j Revised 6-6-2018
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