GW1-2021-02285_Well Construction - GW1_20210722

d
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 4
1.Well Contra or In or Non:
14.WATER ZONES .
Well Contractor Name - FROM TO DESCRIPTION
2 �( q� 4aft. ft. 3 � �
it. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi cased wells OR LINER if a livable
Barnette Well Drilling, Inc. FROM TO DL4�•IETER THICKNESS MATERIAL
Company Name tJ/_ l�C
D ft. ft. in. Sp, L-t C
G/ _. `� MANNER CASING OR TUBING "�e'thermal closed-loop)
-
2.Well Construction Permit#: J FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits .e.UIC,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) nResidential Water Supply(single) ft. R.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. O fL Cement/Sand Poured
❑Monitoring ❑Recovery ft. It.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑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!Re,grain size,etc.)
0 ft. Zv ft.• pv,Pti uti
4.Date Well(s)Completed: ��� 2 Well ID# CJ el` ft L vU ft 17
4
5a. ell Local°n:
J/ d tt5 AS (fo Lt 2t e Z, ft. fL
Facility/Owner Name / D y Facility
ID#(if applicable) ft. ft. v e»9
S J J 7u(../` P C/t W0 1 �tl V ft. ft
Physic ddress,City,and Zip fL ft.
so 21.REMARKS
County Parcel Identification No.(PIN) ,�iia11 ?CCGac.Slrig Unit
�n
D�Y�•;,;c::,lon
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certifie 'on:
? °Zc/ (� L1 N ? � SCE- WIA
6.Is(are)the well(s): &ermanent or ❑Temporary Signature of Certified Well Contractor, Dale
By signing this form,!hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or P. 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:
S.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: goo 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@100D
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: t!J (ft.) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+j, I
11.Borehole diameter: 6 ,/ (in,) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(NC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AI r 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
FOR WATER SUPPLY WELLS ONLY: ! ! 4
24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
�?13a.Yield(gpm) Method of test: 1 '0 to Permit Program, 1611 MSC,Raleigh,NC 27699-1611
! 1
13b.Disinfection
type: HTH Amount: 1/2 Cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources' Revised 6-6-2018