GW1-2021-02288_Well Construction - GW1_20210722

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
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Ld-. 1`-o 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3�r� � � Zpft. / ft. � �
dt. 56
o ft. 1�
NC Well Contractor Certification Number 15.OUTER CASING for multi ased wells OR LINER it a licable
Barnette Well Drilling, Inc. FROM TO DIAMETER :THICKNESS MATERIAL
ft 6 / !; in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: �F FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) 6 ft. O ft. I in. S 6 OVPS
3.Well Use(check well use): ft. fL in,
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public et, ft. in.
❑Geothermal(Heating/Cooling Supply) IJResidential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Ott. '2 O ftPeffemYgafd.Poured
❑Monitoring ❑Recovery ft. fL
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
:19.SANDIGRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control fL 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,%1,/rock type,grain size,etc.)
6 ft. ft. O 2 26o u ik O J
4.Date Well(s)Completed: S '2® Well ID# ft. fJ ft.
5a.Well Location: le.[O ft. ft 0"�`0®�
eltAf
Facility/Owner Name Facility 1D#(if applicable) ft. ft.
Physical Address,City,and Zip ft. ft. l
ee PS v 7-9
G� 21.REMARKS• fi
County tJI Parcel Identificcaation No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ofi
'^CIT 3iivTi�'P^,fG'SSICI�� i�
(if well field,one lat/long is sufficient) 22.Certification
6.Is(are)the well(s)• [!]Permanent or ❑Temporary Signatu a ofCertified 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 ONo 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 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: 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 dierent(example-3@200'and 2@I00�
i
S"�O 24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter: (in,) 24b.For Injection Wells: Copylto DWRI Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
I ,
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 producin�over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
/® Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTr 1I...11 l Amount:
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources' Revised 6-6-2018
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