GW1-2021-05608_Well Construction - GW1_20211015

WELL UUANIXULI1U1N KLUC)Kll KiW-1) For Internal Use Only:
1.Well Contractor Informatiron:
fo f11 fu I f f P2 14.WATER ZONES
G FROM TO DESCRIPTION
Well Contractor Name
Ct0 ft. /©6 ft .6a
�'
5�'�6 Y6 ft. / Z.d ft / 1 /3d iD
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if applicable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft-
t ft- 6 in.
16.INNER CASING OR TUBING eothermal closed400
2.Well Construction Permit#: 3FROM TO DIAMETER 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 DIAMETER 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
❑hri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. I@ red Poured
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery El Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control it. it.
❑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,soil/rock e, rain size,etc.)
® fL 6 ft VPR btJ
4.Date Well(s)Completed: .z�'21 Well ID# -5 Z 6rt. ` .z ft.
5a.Well Location: rt. Z/ ft. _ 4,iM-
274u d No/dam 6 ft c9 1
ft. o,
Facility/Owner Name Facility ID#(if applicable) ft. ,,..
Physiicci Ad ess,City,and Zip p 7 ft ft. OCT I
A.) l�V// d l J�Q 1 3��J�� 21.REMARKS ..
County Parcel Identification No.(PIN) - „14iCi11 i7CCCDf Stet Unit
E
... upJR t3^a; 11
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUI/o�ng is sufficient) 22.Certification-
341 3` SC to�'�- N 79, 3 f� W fi! a 7-
6.Is(are)the well(s): M311'e-rmanent 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
S 7.Is this a repair to an existing well: Dyes or NO 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
IJ'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: w0 (ft.)
For multiple wells list all depths ifili ferent(example-3Q200'and 2®100D Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: Z (ft.) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617IMSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Rotary
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Ai r Rota't-,7
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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing!over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Z I� Method of test: r�/OtlJ P�
13b.Disinfection type: HTH Amount: 4/ j
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018