GW1-2021-05751_Well Construction - GW1_20211015

WELL UQ1NN1KUU'11U1N KL+'UORD (UW-1) �For Internal Use Only: I
1.Well Contractor Information:
y.' �r 10�1 !^ 21
C.L.i 1�i.WATER ZONES
Well Contractor NameFROM TO DESCRIPTION
�✓ / G J p ft. 2-�6ft. Z a
NC Well Contractor Certification Number 2-go ft. Z �ft. J f p i 7® 1 D
Inc. la OUTER CASING for multi-cased;wells)OR LINER if a licable G� �J
Barnette Well Drilling, c FROM TO DIAMETER THICKNESS MATERIAL
Company Name Q ft. 6-.? ft. 6 A in. I f l �U
16.INNER CASING OR TUBING geothermal closed�--loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Countv,State, Variance,etc.) ft. ft. i in.
3.Well Use(check well use): ft. fL in.
Water Supply Well: i7.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) g, ft, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT,
❑Irri ation ❑Welis>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft, Zn
ft. Cement/Sand Poured
❑Monitoring ❑Recovery
Injection Well:
❑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 ft TO ft DESCRIPTION(color,hardness,soil/rock e,grain size,etc.)
AD 6t, i2
4.Date Well(s)Completed: 6 19--Zf Well ID# ZZ ft. S ft.
5a.Well Location: ft. -1 AV
ft. $jtJ 5,9,1� r
,- ft. �.
Facility/Owner Name Facility ID#(if applicable) s ft. 4 odt. Kjg
C ft. ft.
U ft. ft.
Physical Address,City,
,and
/Zip
-
Cc k� "� 3 9-o 21.REMAR1cS,
County Parcel Identification No.(PIN) O !1'•^'1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fat/long is sufficient)
/ l p 22.Certification:
0 N 70- �Z � 2 W
6.Is(are)the well(s): rmanent or ❑Temporary Si�ure of Certified'Well Con factor 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 ItNo 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: [ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: T ©y (ft.)
For multiple wells list all depths if different(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original foim to.Division of Water Resources (DWR),
10.Static water level below top of casing: �_ (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
t
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
h
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing`over 100,000 GPD: Copy to DWR,CCPCUA
s G �pp (b Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) ( J�IT1� Method of test: A11,6 �
13b.Disinfection type: i ITU Amount: /� CUp �0 CS i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018