GW1-2021-05757_Well Construction - GW1_20211015

WELL t;V1NN1KUU11V1N KEI:VKlI (UW-1) I For Internal Use Only: I
1.Well Contractor ln�fo[rmatio :
.�.� 14.WATER ZONES.' I 1
Well Contractor Name "s�3yj FROM TO DESCRIPTION
0 ft. f ft. q f
NC Well Contractor Certification Number TIN 15.OUTER CASING for multi cased'wells OR LINER.(if a livable)
Barnette Well Drilling, Inc.O�� 1 _„ f},,c ;� °}`� FROM TO DIe1 ETERi THICKNESS MATERIAL
0 ft. f ft r� • I ''in. ,`b
Company Name r � � ` z••".i 1 A 4, � 16.4NNER CASTING OR TUBING eother al closed-loop)
2.Well Construction Permit#: `� 'E' FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.VIC,County,State, Variance,etc.) ft. ft. k 'in.
3.Well Use(check well use): ft. ft. ! in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER'
SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential 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- ? ft. Cement/Sand Poured
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicableY
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. fL
❑Experimental Technology ❑Subsidence Control ft. fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) D ft. 3 t5 ft.
t>p L+
4.Date Well(s)Completed: 2, Z Well ID# A / ft. ft ` %
5a.Well Location:1 / I c� ft. ft
C�-e ,u( l X, A- 6 ( It. ft.
Fa acciility/Owner ame �✓ y� Facility ID#(if applicable) ft. ft.
( 6Q 5 t?'e,;r & t Rw ft. fL
Phy�al Address,City,and Zip G 2,�S 7 ft. ft.
/"C/1,S 0A__ g Z 21,'REMARICS,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certific 'on
�G 2 6. 9 ?q�/ N 74'5536) 117 w - 7
6.Is(are)the well(s):�Permanent or ❑Temporary Signat•e o Certified Well Contractor Da
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If 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 jto 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.
i
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: NO O (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(examp e- @200'annd 2@100D
p g U (ft.) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below to of casing: 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 jDWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air Rota 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,directpush,etc.) county environmental health department of the county where installed
1
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
1_1T1 l
6 /0 Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: nun Amount: 1/2 C U p
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018