GW1-2021-05755_Well Construction - GW1_20211015

WELL CONSTRUC'1'IOIN RECORD(GW-1) I For Internal Use Only: y
1.Well Contractor Information:
WWATERONESWell Contractor Name :; � = ) TO DESCRIPTION
ffCift.':i'`12 © rt. 6NC Well Contractor Certification Number � r�('a1 . ASING for multi�ased wells OR LINER if a livable
Barnette Well Drilling Inc. `` 1;�:' goy TO DIAMETER THICKNESS MATERIAL
Company Name `,ly s: p` ft. z fL i, �F in. fir'NSF Z C�
V' 16.INNER CASING OR TUBING. eothermat closed-too
2.Well Construction Permit#: / FROM TO DIAMETER THICKNESS MATERIAL,
List all applicable well construction permits(i.e.UIC,Countv,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.$CREEK
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I8.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. fL Cement/Sand Poured
❑Monitoring ❑Recovery IL ft.
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 ❑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 e,grain size,etc.)
�y l G rt. ft 6 w- J
4.Date Well(s)Completed: ��3 V / Well ID# � ft. t5 ft. ex Lip,
�,
rt. 3 cr3 Sa.Well Location: ,[� P
C0 0 /Z�'�1f�� (.Z en., S" ft- 7� fL l�l/?��31`���' 'I'-.516`Y
Facility/Owner Name Facility ID#(if applicable) f' ft. 6- /r
0 J &-or" 4 f`- 7 It ft. ft. v
Physical Address,
City,and
Zip ft. ft.
Of'rc-S Ste' ��j 21.REI4IARICS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification-
6.Is(are)the well(s)• [!�Kermanent 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 welk ❑Yes or V00 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 of this retard 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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2_ d (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@100')
10.Static water level below top of casing: 7i (ft.) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
If water level is above casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: le (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
12.Well construction method:AI r Rota
ry Program, 1636 MSC,Raleigh,NC 27699-1636
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,directpush etc.) 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,NC 27699-1611
13a.Yield(gpm) P6, �1 Method of test: /d
13b.Disinfection type: HTH Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018