GW1-2021-02339_Well Construction - GW1_20210722

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w.e.L,L,l;U.NNTKUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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A iU/�zp_ �, � (�`� 14•WATER ZONES I ;
Well
Contractor Name FROM, To T DESCRIPTION
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5"D IL
Well Contractor Certification Number J�
ft. Gp.6 It-
NC
15.OUTER CASING for multi-eased wells)OR LINER if a livable
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 6 ft. 2 ft ( in. ', -rAR Z 1 G/.!
`� 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: Q 7 FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.} 6
ft. flo R. in. V
s Z r�
3.Well Use(check well use): ft. v ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipaVPublic ft. ft in.
OGeothermal(Heating(Cooling Supply) Mikesidentiai Water Supply(single) g• ft in.
Olndustrial/Commercial OResidendal Water Supply(shared) 18.GROUT
OIrri ation •Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft Cement/Sand Poured
❑Monitoring ORecovery ft. �'� ft ; l
Injection Well:
ft ft.
•Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
OAquiferTest OStormwater Drainage It
OExperimental Technology OSubsidence Control ft. It
OGeothermal(Closed Loop) •Tracer 20.DRILLING LOG attach additional sheets if necessa
•Geothermal(Heating/CoolinggrReturn) OCtther(explain under#221 Remarks) FROM TO DESCRIPTION(color,hardness, iltrock type,drainsim etc)
4.Date Well(s)Completed: r I2- 0 Well ID# ft. 2 IL S"di
Sa.Well Location: ! fr. ft. RAee��a/ S
4144f7X (61,;y 4 ?-,6 tt. Z Z rt
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ft ft c4 '
/ Ga2t7ss '� Azz Z 91 R I,ts&je L"t'i 4 e e J
Physical Address,City,and ZIP / }
. 13 21.REMARKS
JUL !n
County Parcel Identification No.(PIN)
a: r,rOr Dc s1lif�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �-
(if well field,one lattlong is sufficient)
22.Certification �
39 • 3k_-JS y N 7S_ s 8A(fl?
6.Is(are)the well(s): MP-ermanent or OTemporary Signature-if Certified well Contractor Date
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By signing this form,I hereby cent/ that the weit(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or 6K1_ 15A NCAC OdC.0100 or 15A NCAC 01C.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:
&.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)
For multiple wells list all depths ifdierent(example-3Q200'and 2@1001 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: z,v5 (ft.) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
If water level is above casing,use"+' Information Processing Unit,1617i MSC,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 constriction 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 producin d over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpm) 2� Method of test:
13b.Disinfection type: HTH Amount: 1/2 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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