GW1-2021-02286_Well Construction - GW1_20210722

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j
�Fil�rZ�i G_ .Ifs LB_L 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
cis-ft. �D D ft.
76 7437t. iS"S ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a licable)
Barnette Well Drilling Inc. FROM TO DIAMETER TLIICICNE& MATERIAL
r ® ft. 6 2 ft L � in. SdR.? t �(�C
Company Name 16.INNER CASING OR TUBING 'eothermal closed-loop)
2.Well Construction Permit# FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.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) dResidential Water Supply(single) ft ft. i�•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: , ft. ft Cement/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
rt. rt.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a "licabte
❑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 additionabsheets.if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
O fc. ? ft. t142 2
4.Date Well(s)Completed: � -&7 Well ID# 3 ft. ft. r LSO 5a.Well Location: t ��,(��{ ` rt• ICY I- o Cl�
wj& ' og /-�//3 �.�f t DE)f L
Facility/Owner Name { Facility ID#(if applicable) ft. ft.
o �e/'�R ft ft �*
Physical Address,City,and Zip ft ft.
_ e , 21.REMARKS
IV jut .�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �r^.ce�str1�� tJl�it
.:r.Q
(if well field,one lat/long is sufficient) 22.Certification: 0i ;Z:C
,3 f e3s"9V V N 7 `' i73 w
6.Is(are)the well(s) anent 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 t I o 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 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: / o (ft.) Submit this GW-1 within 30 days of well;completion per the following:
For multiple wells list all depths if diJjerent(example-3@200'and 2@100)
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: Z- (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use
11.Borehole diameter: (in.) 24b. For Injection Wells: Copy ItoDWR Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 276994636
12.Well construction method: AI r 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 producing over 100,000 GPD: Copy to DWR,CCPCUA
�� Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test-
1� i
13b.Disinfection type: HTH Amount: Uzl�w /30- w E
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resourcl s!' Revised 6-6-2018