GW1-2021-05754_Well Construction - GW1_20211015

WELL l:U1NJ1KUk_11U1N KEUL)" (UW-I) I For Internal Use Only:
1.Well Contractor Information:
L 14.WATER ZONES 1
Well Contractor Name` FROM TO DESCRIPTION
ft. l Cab ft. l
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
Company Name ft. ft 17 in.
j 16.INNER-CASING OR TUBING eother al closed-loop) V
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DLAeMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. OUred
❑Monitoring ❑Recovery ft'
t ft.
Injection Well: ft' tt.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑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)
TO
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM tt. ft. DESCR IPTION(color,hardness,soil/rock type,grain sue,etc.)
4.Date Well(s)Completed: 2 2( Well ID# ft. / z ft. Q e n
5a.Well Location: C 2- ft. 3
C and 1J�/t�,/�l� ft. S zp ft. G-r,,ey koe,Je
Facility/Owner Name Facility lD#(i(�ifa/p'plicable) ft. ft.
it ft.
Physine
ddress,City,and Zip
rt. ft. }
esee� 21.REMARKSCounty Parcel Identification No.(PIN) ...r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaVlong is sufficient) 22.Certification:
6- f�_673L� N 78'. ly 5"9 . w (fo f _ sa 7 2z Z/
6.Is(are)the well(s)• permanent 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 -x0 I5A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fell 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-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: �Z 2> (ft.
For multiple wells list all depths if dierent(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: ZtJ (fk) 24a. For All Wells: Original fo; 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, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air Rotary i
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 producing lover 100,000 GPD: Copy to DA R,CCPCUA
©� Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) � Method of test:
u 1�
13b.Disinfection type: HTH Amount: ?ffewZ 3 Z�
I
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources', Revised 6-6-2018