GW1-2021-05756_Well Construction - GW1_20211015

VV r LL %_"Ira A INU%_11"1,4 se r,%-"X o I V VV-1 I I ror lnrernat use unry:
1.Well Contractor Information:
17 U�V y IC e E: 14.WATER ZONES
Well Contractor Name
i.,a,:. .l'• ,, FROM TO DESCRIPTION
�y:,�q> 7s I
�1 rt. ft.= 3 '
NC Well Contractor Certification Number �I ij �O `'} 1 OUTER EASING for multi cased well OR LINER if a 1*1e
Barnette Well Drilling Inc. \ , FROM TO DIAMETER THICINESS MATERIAL
r=...,
f ft. ( 2 ft. f' in. S �2) f/ (✓��
Company Name
16.INNER CASING OR TUBING.(geothermal closed-loop)
2.Well Construction Permit#: /y V FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Countv,State, Variance,etc.) rt. ft. 1 in.
3.Well Use(check well use): ft. f[. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL ft. in.
❑Geothermal(Heating/Cooling Supply) ARCe-s dential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑1r ri ation ❑Wells> 100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 2-C)fL Cement/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVELPACK dapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. IL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
TO
❑Geothermal(Heating/Cooling Return)
) ❑Other(explain under#21 Remarks) ft TO
DESCRIPTION(color,hardness,soil/rock type, rain size,etc.)
4.Date Well(s)Completed: e- Well ID# /T f 5' ft /S-- ,.L �r� •i
5a.Well Location: J5- ft. .3-r,,- It,
-5- ft. ft. u
'yam q ,��R�"�Facilityy//jOwner Name Facility ID#(if applicable) ft. f[.
VY /�7L Hj Dll6 Ly
Physical Address,City,and Zip ft rt
fe fz Vg 6, .j ' -Y-& 21.REMARKS
County Parcel Identification No.(PM)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36e 'V6-32b N J9 Q9 W
6.Is(are)the well(s)• ffiKermanent 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 [!�<o 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
1f 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-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: 5006 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q206'and 2@100)
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: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air 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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing ver 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) T
j 'b Method of test: Permit Program, 1611 MSC,Raleigh,NC 27699-1611
C4 ZrO23b.Disinfection type: HTH Amount: "�'"P *p D -
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018