GW1-2021-02283_Well Construction - GW1_20210722

WELL CONSTRUCTION RECORD GW-2 For Internal Use Only: �k
1.Well Contractor Information: I k
ell)
b A./efIl �' . ��Lf..a �'¢ 14.WATER ZONES E ';
Well Contractor Name FROM TO DESCRIPTION;
3 3 7 10 ft. 1 r— ft. �
0 C, ft, jr/0 rt !2 i9
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER(if a licable)
Barnette Well Drilling, Inc. FROM TO DIAIDIETER THICKNESS MATERIAL
Company Name a ft. t7 it. in. •.$G,LI'1 7-1
�) 16.INNER CASING OR TUBING eothermal closed-Ion
2.Well Construction Permit#• LS FROM TO DIAMETER TffiCKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Coun(v.State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ct. in.
Water Supply Well: 17.SCREEN i
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OAgricultural OMunicipal/Public ft. ft. ;in.
i
OGeotbermal(Heating/Cooling Supply) InResidential Water Supply(single) ft. ft. :in.
❑Industrial/Commercial OResidential Water Supply(shared) 18 GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ® rt '� ft Cement/Sand Poured
OMonitoring ORecovery ft. ft.
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK of a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage ft. ft.
OExperimental Technology 0Subsidence Control ft. ft.
OGeothermaI(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) OOther(explain under#21 Remarks) FROM i To DESCRIPTION(color,hardness,soittrock type,grain sae,etc.)
_ram ft. ft in
4.Date Well(s)Completed: i�'�"�r Well ID# It.
Sa.Well Location: l Z ft gr- ft Alto o WA- eg e t
Facility/Owner Name Facility ID##(i(f�app)icable) ft. ft.
126 c
Physical Address,City,and Zip
ft. ft. V V
e /l 21.REMARKS
A
County J
UL
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Y ` *orOs;el Unit
(if well field,one lat/long is sufficient) g� 22.Certification: (�'l;vt iz:.ledioll
4t-11 7l— N 7 G7 'S j -""6 W
6.Is(are)the well(s): 9deeirmanent or OTemporary Signature of Certified Well Contractor Dare
By signing this form,l hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or MWo`' 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 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 lest all depths!f different(example-3@200'and 2Q100')
�I.
2 24a. For All Wells: Original form to.Division of Water Resources (DWR),
1f water level is above casing,use
10.Static water level below top of casing: (ft Information Processing Unit,1617 iMSC,Raleigh,NC 27699-1617
"+" ;
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWR,:Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Rota'7nf
24c.For Water Supply and OpenL'Loop Geothermal Return Wells:Copy to the
(Le,auger,rotary,cable,direct push,cte.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producinglover 100,000 GPD: Copy to DWR,CCPCUA
�� Permit Program,1611 MSC,Raleigh,iiNC 27699-1611
�
13a.Yield(gpm) ® Method of test:
13b.Disinfection type: HTH Amount: /,d 0 '
f
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources t_ Revicgrl r.r._7n12