GW1-2021-05629_Well Construction - GW1_20211015

For Internal Use Only:
1-Well Contractor Information:
4 l ES
Well Contractor Name 14.WATER ZON �
—3 FRO o TO DES i -.RIP
q TI
!� 9 ft. 106
06 ft.
NC Well Contractor Certification Number ft• el ft -
Barnette Well Drilling �+ 15.OUTER CASING(for multi-cased wells OR LINER()f a licable)
t Inc. FROM TO DIAMETER THICKNESS
Company Name 0 ft. 6_3 ft in. MATERIAL/ ^f S
2•Well Construction Permit# f`' 16.INNER CASING OR TUBING eothermal closed-loo ���
List all applicable well construction permits(i.e.UIC.Colin y Variance,etc.) FROM rt ft. in.TO DIAMETER TMCKNESS yATER
3.Well Use(check well use): ©
ft. ft. in.
Water Supply Well; 17.SCREEN
❑Agricultural ❑Municipal/Public FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Geothermal ft ft. in.
(Heating/Cooling Supply) C1Residenrial Water Supply(single)
❑Industrial/Cotnmercial ft ft in.
❑Residential Water Supply(Shared)
❑hTi a[ion 18.GROUT
❑WellS>100,000 GPD FROM TO Non-Water Supply Well: MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Monitoring rt' CU ft Cement/Sand Poured
❑Recovery ft
Injection Well: fL
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
❑Aquifer Storage and Recovery ❑Salinity Barrier 19,SAND/GRAVEL PACK if a licable
❑Stormwater Drainage ft.
❑Aquifer Test FROM TO MATERIAL EMPLACEMENT METHOD
ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer ft ft
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2l Remarks) FROM To
DESCRIPTION(coloq hardness,soiUrock e, in sue,etc.)
v ft ? ft
4.Date Wel(s)Completed: `�5-Z Well ID#_+L 2. 1 d 2 J r rt. � ft 9 e''e—h L,2 ©w
_
5a.Well Location:
Facility/thvner Name Facility ID#(if applicable) ft ft.
WS ft. ft.
Physical Address,City,and Zip
9 y� ft. ft. n
0���q� `perZ 21.REMARKS
County Parcel Identification No.(PIN) v, �•;. 3'%CyS'r ^�,,lyC'{1
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:(if well field,one lat/long is sufficient)
3 '2 '7 22.Certification:
6.Is(are)the well(s): rmanent or ❑Temporary r���N
Signature of Certified Well Contractor
Date
7.Is this a repair to an existing well: ❑Yes or 6N — BY signing this form,1 hereby certifv that the wells)was(were)constructed in accordance with
15,4 If this is a repair,fill out known well construction information and explain the nature of the f his record has b e provided 10 the well owner.
Construction Standards and that a copy
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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
9.Total well depth below land surface: 24.SUBMITTAL INSTRUCTIONS
For multiple wells list all depths if different(example-3@2
erent � and 2d 2@I00� (ft)
Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (ft) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
Ijwater level is above casing,use"+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells:Copy to DWR,Underground Injection Control all)
12.Well construction method: Air Rotary Program, 1636 MSC,Raleigh,NC 27699-1636
(i e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells produciu¢over 100 000 GPD Copy to DWR CCPCUA
13a.Yield(gpm) 12l u� Method of test: /p(� Permit. 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTf, Amount: 13400
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-201 R