GW1-2021-05750_Well Construction - GW1_20211015

WELL (:4_)1Nb1KU(:11U1N KINU"" (kXW-1) I Por internal useUn►y:
1.Well Contractor Information:
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e— Y^ 1 14.WATER ZONES
tt Well Contractor Name FROM TO DESCRIPTION
ft.
' ft. 7u ft /9
NC Well Contractor Certification Number 15.;OUTER CASING.for multi-cased wells OR LINER(if a livable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft j� ft g / in. I Jrd k 2
Company Name 10
16.INNER CASING OR TUBING' eothermal closed-loop)
2.Well Construction Permit#: 71 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. VIC,Countv,State, Variance,etc.) if) ft. f it. In. '40
3.Well Use(check well use): ft. rt. in. ff"�
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
[]Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (� ft. ey rt. Cement/Sand Poured
❑Monitoring ❑Recovery
Injection Well:
ft. rt.
❑Aquifer Recharge El Groundwater Remediation
19:SAND/GRAVEL PACK ifapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. rt.
❑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,soll/rock type,grain size,etc.)
6 ft_ It 0 ife Ifbo aej o,J
4.Date Well(s)Completed: 1:1"L 1 Well ID# "IV_73 ft. b ft.
5a.Well Location: ft. d ft.
lb ft.
Facility/Owner Name / Facility ID#(if applicable) �� ft. ft. G G
l�
Physical Address,City,and Zip
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21:REMARKS
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County Parcel Identification No.(PIN) P 4 S21
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
r.-n
(if well field,one]at/long is sufficient) 22.Certification: r "') s 'tea r5 `
'."s •,�t� ;;fin,
6.Is(are)the well(s)• O�P&manent 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 L'-No 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,,fall 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: 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 ifdierent(example-3@206'and 2@100)
cf-- 24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: v (ft.) Information Processing Unit,16171MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" i
11.Borehole diameter (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Ai r Rotary 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
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
/13a.Yield(gpm) Method of test: �� Permit Program, 1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: H I TL1 n Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources! Revised 6-6-2018