GW1-2021-02283_Well Construction - GW1_20210722 (2)

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name Le y6ft. 5100 ft. ,4 ems•
3 ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells O&LINER if a livable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS ERIAL
O ft. 7 6 ft. 6' A in. J. 2
Company Name J� 16.1NNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: 7 D FROM TO DU4METER TffiCKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft• fL in.
3.Well Use(check well use): ft. ft m
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICWNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. In•
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑hidustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: rt. ft. GemeaUSand Poured
❑Monitoring ❑Recovery U ft. ZiD rt. e I
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applivable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage fL ft.
❑Experimental Technology ❑Subsidence Control ft. fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soillrock e, in size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
n rt. S ft. e i2 tou J_-S d
4.Date Well(s)Completed: Z3'�/Well UD# �7 [/ ft. 1 ft s- eck C��
S- ft. fL )C J ~
Sa.Well Location: �
/Y6xoC-k ft. D IL a.6 4-
Facility/O ner Name Facility ID#(if applicable) ft. � el-r,fL tij G&
ft.
Physical ddress,City,and Zip ft. ft r
6� � / 21.REMARKS
�/ -, O
County Parcel Identification No.(PIN) Q2�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: )
(if well field,one IaVlong is sufficient) 22.Certification: III" N =E jion
N - r� 3 t�7 D Wile
6.Is(are)the well(s): �manent 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 650-- 15A NCAC 02C.0100 or 15A NCAC 62C.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: t� 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-3Q200'and 1Q100')
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1611 MSC,Raleigh,NC 27699-1617
if water level is above casing,use"+"" ,
(in.) 24b. For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air Rota °
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 produci ng`over 100,000 GPD: Copy to DWR,CCPCUA
6� Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) -it 15 Method of test:
13b.Disinfection type: HTH Amount: cup
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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