GW1-2021-05752_Well Construction - GW1_20211015

----- - ror Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name Mft. DEDESCRIPTION
NC Well Contractor Certification Number r multi cased wells OR LINERa livable)
Barnette Well Drilling, II1C. DIAMETER THICIGVESS MATERIAL
Company Name 6 //.
d 16.INNER CASING OR TUBING e;tliermal closed-
7loo
2.Well Construction Permit#: ® FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permus j.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. tt in
F
ter Supply Well: 17.SCREEN cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
�' ❑Municipal/Public FL ft. ineothermal(Heating/Cooling Supply) MResidential Water Supply(single)
ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared)
❑Irri ation t8.GROUT
❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&PuMOUNT Non-Water Supply We1L• b rt It. Cement/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
❑Aquifer Storage and Recovery19.SAND/GRAVEL PACK if a livable
❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. fL
❑Geothermal(Closed Loop) ❑Tracer Z'l1.DRILLING LOG(attach additional sbeets if necessar
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(rotorr,hardness,solVrock e,grain size,etc)
U ft. f
t.
4.Date Well(s)Completed: `ZS 2/Well ID# 7® ft.
Sa.Well Location: Z ft. U ft. t
Facility/Owner ie Facility ID#(if applicable) ft. ft.
ft. ft.
Physical Address,City,and Zip ft. ft. ■
Q IK'Q/v � 2.11.REMARKS ~ 1
County rrir;.n �;iu{
Parcel Identification No.(PIN) ,,,.rsr, ,_,•;,r•.:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient)
22.Certification:
ryVer—
f IS(are)the Well(S): lmanent or ❑Temporary signature of Certified Well Contractor Date /
0v!signing this form,I hereby certifv than the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the ivell 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 1 to provide additional well construction info
construction,only 1 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 ifdii ferent(example-3@200'and 2@100) ( Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: �-s (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: (in.)
24b.For Injection Wells: Copy to+DWR,Underground Injection Control(IUC)
Program
12.Well construction method:Air Rotary , 1636 MSC,Raleigh,NC 27699-1636
(i.e.auger,rotary,cable,direct push etc.) 24c.For Water Supply and Open Loop Geothermal Return Wells Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 246.For Water Wells producing of er 100 000 GPD• Co to D
,/� p PY WR CCPCUA
13a.Yield(gpm) �0 Method of test: 040 u7 Pemut Program, 1611 MSC,Raleighf NC 27699-1611
I'Cup /q
13b.Disinfection type: HTH Amount:
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018