GW1-2021-00525_Well Construction - GW1_20210315

••Lam.%1%J1va ixuL'11uN RECORD(GW-l) For Intemal Use Only:
I.Well Contractor Information:E+ d'.
�J
�_ t1-a* 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
33 76- �ft /e ft
NC Well Contractor Certification Number Z 5,5-It 2 a ft.
15.OUTER CASING for multi-cased wells OR LINER ff a livable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name
O ft' I?f ft 418,
In St��1 a(
16.INNER CASING OR TUBING enth. al closed-loo
2.Well Construction Permit#: 1.0 S FROM To I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits ge.UIC,County,State.Variance•etc.) ft Ct. in.
3.Well Use(check well use): ft fL in.
Water Supply Well: 17.SCREEN
FROM TO 7in.
OT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft❑Geothermal(Heating/Cooling Supply) nResidential Water Supply(single) R, ft
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
01r i ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft ft Cement/Sand Poured
❑Monitoring ❑Recovery ft tt.
Injection Well:
❑A uifer Recharge ft ft
4 urge ❑Groundwater Remediation
uifer Storage 19.SAND/GRAVEL PACK f a licable
❑A
q rage and Recovery ❑Salinity Barrier FROM TO I MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft
❑GeOthermal(Closed I oop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION(color,hardness,soil/rock type,grain size,eta
ft ft
4.Date Well(s)Completed: Z�Z� Well ID# ®� ft Z8 ft
5a.Well Location: a IL B ft R � /
iyeaAeaibeR-pex o `t 815'
Facility/Owner Name Facility ID#(ifapplicable)
g'tv v� & ocl
J?3 L e ws S W i saw f¢e J9 e� ko too- 9, -•— ft ft
Physical Address,City,and Zip V ft ft.
21.REMARKS
County Parcel Identification No.(PIN) r, —
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient)
22.Certification: �:. ` `• ' 1 1
3,9-36622- N /97
6.Is(are)the well(s): Mfe'rmaneut 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 &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 mature 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 OW-1 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: � D� (ft)
For multiple wells list all depths tjdffferent(example-3Q200'and 2p1001 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: Z%r (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: t� (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Air Rota Program,1636 MSC,Raleigh,NC 27699-1636
(Le.
L a.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
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 over 100 000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC-000 I I
13a.Yield(gpm) / Z Method of test:� /VA;
13b.Disinfection type: HTH Amount: la&
Fomr GW-1 North Carolina Department of Environmental Quality-Division of Water Resources \ Revised 6-6-2018