GW1-2021-05748_Well Construction - GW1_20211015

--- ­`1rt" aAVIN IMUORD GW-1 !
For Internal Use Only: j
I.Well Contractor Information:
(. /0
Well COR .UjOr Name 14•WATER ZONES C
FROM To DESCRIPTION
NC Well Contractor Certification Number z/�ft. ��ft. Z Jql p,U p /0
Barnette Well Drilling Inc. 15.OUTERCASiNG for multi-cased wells OR LINER e
(ifa livabl )
FROM TO DIAMETER THICKNESS MATERIAL
Company Name ® ft Q ft /p in.
Well Construction Permit#:—���
16.INNER CASING OR TUBING eotherroai closed-too C VC-_
List all app!lcable well construction permits(i.e.UIC,County,State, variance,etc.) FROM TO ft DIAMETER THICKNESS
MATERIAL
ft.
3.Well Use(check well use): in.
ft. ft in.
Fh-
Supply Well: 17.SCREEN
[]Agricultural ❑Municipal/Public FROM TO DIA METER SLOT SIZE THICKNESS MATERIAL
hermal(Heating/Coolin Supply) ft. ft. in.
g PP Y) ®Residential Water Supply(single)
striaUCommercial ft
❑Residential Water Supply(shared)
ation 18.GROUT
❑Wells>100,000GPD FROM To ater Supply Well: MATE�AL EMPLACEMENT METHOD&AMOUNT
ft' Z�ft CemenVSand Poured
itoring ❑Recoveryon Well: fL g•
fer Recharge ❑Groundwater Remediation ft• ft.
fer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK da livableer Test FROM TO MATERIAL EMPLACEMENT METHOD
❑Stormwater Drainage ft ft.
imental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ft. ft
❑Tracer❑Geothermal(H 20.DRILLING LOG attach additional sheets if necessa
eating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM To
DESCRIPTION(color,hardness,soiUrock e• is size,etc.).
_ �J ft. T ft.
4.Date Well(s)Completed: `s'•� �� Well ID# �/}` l
i ft. ft s.
Sa.Well Location: S a
ft.
ft,I)j4/y 199� 2�t 3�0 ft R� C
Facility/Owner Name i
Facility ID ft. ft
#(ifapplicable) KG G �`
Z�Y-6 1q0ll,-,4 /7r-J1< - ft ft
Physical Address,City,and Zip ' _ r
County
Parcel Identification No.(PIN) CT ;�
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well
field,one ladlong is sufficient) t..;t;il
—,�C7.. 3•S� 7 N 22.Certification • lii:Cl�:l:�: � ^�;`^'1
�`? ts��
6.Is(are)the well(s): ermaaent or ❑Temporaryf f- — '� �'` �'—s�'L Signature of Certified Well Contractor
Date
7.Is this a repair to an existing well: ❑Yes or QNp ev signing this form,1 hereby certify that the wells)tias(were)constructed in accordance with
(this is a repair,fill out known well construction information and explain the nature of the J his record has been provided to the2C.00wel1 owe. Construction Standards and that a copy
repair under#21 remarks section or on the back ofthis form.
23.Site
8.For Geoprobe/DPT or Closed-LoopYou may Geothermal Wells having the same yuse the back of this pageagrarn or additional )oeprolvide 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:
9.Total well depth below land surface: 2 v 24•SUBMITTAL INSTRUCTIONS
For multiple wells list all depths if different(example-3@200'and 2@1001 (f t) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 24a. For All Wells: Original forme to.Division of Water Resources (DWR),
IJuarer level is above casing,use (ft)"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I I.Borehole diameter: (in.) 24b.For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
12.Well construction method:
Air Rotary Program, 1636 MSC,Raleigh,NC 27699-1636(i.e.auger,rotary,cable,directpush etc.) 1
24c.For Water Supply and Open-Loop Geothermal Return Wells Copy to the
county environmental health department of the county where installed
ZM:
WELLS ONLY:
� 24d For Water Wells producin ,over 100 000 GPD Copy to DWR,CCPCUA
1—T Method of test: /U Permit Program, 1611 MSC,Raleigh,NC 27699-1611
1 N Amount: �6
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018