GW1-2021-02282_Well Construction - GW1_20210722

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
7 / tA 7.9- '1-40 fL Zara/
�J �O ,`Ia ft. S't D n.
NC Well Contractor Certification Number 15.OUTER CASING for multi-casedwells OR LINER ifa licable
Barnette Well Drilling, Inc. FROM TU DL4M,TER THICKNESS MATERIAL
Company Name D ft. fL 6 l8 in.
lb.fNNER CASING OR TUBING eother al closed-loop)
2.Well Construction Permit#: FROM To DL4IIETER THICKNESS MATERIAL
�
List all applicable well construction permits(i.e.T UIC,County,State, Parlance,etc.) © ft. / d It. in. S J p Z �C
3.Well Use(check well use): ft < ft in. P 1`
Water Supply Well: 17.SCREEN
FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.l
❑Geothermal(Heating/Cooling Supply) Ef6sidential Water Supply(single) fL ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells> 100,000 GPD FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. fL G+EfnoYd8und poured
❑Monitoring ❑Recovery O ft. ft.
Injection Well:
ft. it. i
❑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 ft. ft.
DExperimental Technology El 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,soil/rock type,grain size,etc.)
ft. � ft. Q!/G� �i�GZ-(J� O l✓
4.Date Well(s)Completed: Z!Well ID# C0 Oe
5a.Well Location: 1 LP ft. Zft. �V�C q SO 1
Lo/�/�' �7 7- 'Z f t. ✓ fL / XQ r+ e-
Facility/O r Name Facility ID#(if applicable) 4'5 ft. 5, ft. kn
2� C-4 �•'r� CIAAley n�7 Acoe�vc� ft �v ft '4
Physical Address,City,and Zip ft ft. h"
�az
21.RE1VIARKS
JUL
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat(long is sufficient) 22.Certification-
36. 3 2/�LJ N 7 - 8T W
6.Is(are)the well(s)- &FIe'rmanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,!hereby cert fv that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ®°Piece 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 ofthe ofthis 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: .^�4-d
(ft) i
For multiple wells list all depths if dierent(example-3®200'and 2®100')
Submit this GW-1 within 30 days of well completion per the following:
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
If water level is above casing,use"+-
/ 24b.For lniection Wells: Copy to DWR,'Underground Injection Control(NC)
11.Borehole diameter: o (in.) 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 of the county where installed
1
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing)over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,,NC 27699-1611
13a.Yield(gpm) Method of test: /Ts(®w
l� H '�Id
13b.Disinfection type: HTH Amount: 2-0 -
i
1 ! I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resource ! I Revised 6-6-2018