GW1-2021-05745_Well Construction - GW1_20211015

I.Well Contractor Information: For Internal Use Only:
WATER ZONES I
Well Contractor Name 14. E
7 s FROM TO DESCRIPTION
NC Well Contractor Certification Number ZS`e3ft, �ED)ft.
Barnette Well Drilling, Inc. FROM
TERCASING formulh-casedwells)ORLINER(ifa licable
Company Name ft, ft.
t DIAMETER THICKNESS MATERIAL
� lt�, e in. Sr� 2J 1/L
2.Well Construction Permit#:_ 16.INNER CASING OR TUBING eothermal closed-loo
List all applicable well construction perm,,,(i.e.WL,County,State, Variance,etc.) FROM TO DIAMETER THICKNESS
® ft. � ft. in. MATERIAL,
3.Well Use(check well use): C
rt.
Water Supply Well: 17.SCREEN
❑Agricultural ❑Municipal/Public FROM TO DIAMETER SLOT SIZE TffiCI4YESS MATERIAL
❑Geothermal(Heating/CoolingSupply) ft ft.ft.
PP Y) l7Residential Water Supply(single)
❑lndUstrial/Commercial ❑Residential Water Supply(shared)
ft ft in.
❑hri ation 18.GROUT Wells>100,000GPD FROM
Non-Water Supply Well; TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft Zc� ft- Cement/Sand Poured
❑Monitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation ft• ft.
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK if a licable
❑Aquifer Test FROM TO MATERIAL
❑StormwaterDrainage ft. fL EMPLACEMENT METHOD
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ft ft.
❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM ft To
ft DESCRIPTION(color,hardness,so! rock e, in size,etc.)
4.Date Well(s)Completed: Z f Well ID# 6 Z 111, ft ® /6
ft.
5a.Well Location: f Y G
6 ft
�1 P'
eft 2�o ft
Facility/Owner Name Z t it
Facility ID#(if applicable) ft. It.
ft. ft
Physical Address,City,and Zip
ft ft.
✓ 21.REMARKS � --
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,t
(if well field,one IaVlong is sufficient) ;?_.✓,r{'• "`" .'
3 N �� 22.Certification: ( ,-, ,, w „
W
6.Is(are)the well($): anent or ❑Temporary
Signature of Certified Well Contractor
Date
7.Is this a repair to an existing well: ❑Yes or ftij BY signing this form,I hereby certify that the well($)was(were)constructed in accordance with
Ijthis is a repair,fill out known well construction information and explain the nature of the ol'this record has been provided to the well ow00 ner.
Well Construction Standards and that a copy repair under#21 remarks section or on the back ofthis 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:
9.Total well depth below land surface: ze 24•SUBMITTAL INSTRUCTIONS
For multiple wells list all depths ijdierent(exomple-3®200'and 2Q100� (f h) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: z.% 24a. For Au Wells: Original form to.Division of Water Resources (DWR),
If ivarer level is above casing,use"+' (ft.) Information— Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 0 (in.) 24b. For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
12.Well construction method:
Air Rotary Program, 1636 MSC,Raleigh,NC 27699-1636
(i.e.auger,rotary,cable,directpush,etc.) 24c.For Water Supply and Open-L000p Geothermal Return Wells Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
... 24d.For Water Wells producint:over,100 000 GPD Copy to DWR,CCPCUA
L13b.
ld(gpm) �u Method of test 1f 0®(d Permit Program, 161 I MSC,Ralergh,NC 27699-1611
infection type: HTFi Amount:
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6_7D1A