GW1-2021-05633_Well Construction - GW1_20211015

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1.Well Contractor Information:
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/'l✓ �/`� �` /� (t I14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
1,141
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- 1 ft. ft.
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. 3 ft. in. SC7Le 1C
Company Name
-� 16.`INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:_(k) 1- /a 0 Z Z FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. tt in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DUMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) In Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hTi ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. I C�C1d Poured
❑Monitoring ❑Recovery it.
Injection Well:
ft. ft.
❑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)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiltrock type in size,etc.)
C7 ft. ft. Li C le'6 l-I_i2e(t3
4.Date Well(s)Completed: ^Z--2l Wel1 ID#tJ)j 7-!Jazz 7 3 ft. (v ft ,e C` ,,9
5a.Well Location: ft. 3,1 ft.
, oft. G''►Z ✓ /
Facility/Owner Name I Facility ID#(if applicable)
C. CJ/�(Z 6A t7 C ft. ft �^•
tt it. ,,,, I
Physical Address,City,and Zip a , .>J
21 REMARKS. nn
County Parcel Identification No.(PIN) l l�� O
r-4 �i�•�r i.�Zll
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient)
Q / 22.Certification:
6.Is(are)the well(s): Mr-m-anent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certifv that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Oyes or two' 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 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: / A 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: e!�o V (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100D
10.Static water level below top of casing: t�`10 (ft.) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
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 producingover 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) it Method of test: QJ
!<G/0CLIA Permit Program, 1611 MSC,Raleigh,NC 27699-1611
1� 1�
13b.Disinfection type: H H Amoun: -- -
ft-
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018