GW1-2022-09307_Well Construction - GW1_20221006

4'3'ELL CONSTRIICTION ItECORID t Tbis form can he used for single or multiple wells
For internal Use ONLY:
L Well Contractor Information:
i
K WATER zONSS
Contractor Name
Well ContractorTO 1
3,f 7,6 %�� S�f6 5 hest D Z N
NC Well Contractor certification Number ft ft
1�.. R.F:Ab1rrG for timkiKasedlvdis
13arnette Well Drilling, Once FROM ORLIIXE$'rfa ueatite• ..
TO DL1MErrt�;t
Cor�taay Namc
v ft 15 6"-
2.well Construction permit 'II�IiYCIi I AMP-OR7'OBING eel
PROM TO IAMEIEg erdual.closMl
List all applicable xrl!coastnrction ermlls y e D 7HIC�1E53 MATERfAL P (f e.Count,Slm lrarlorrae,eta) ft ft is
3.Well Use(check well use): tt ft
Water Supply Well: 7Z:SG12$EN:'
❑Agriculoural irROM TO DIAMETER SIZE SLOT
OMunicipaUpuhlic- ft h TBltaavess'
srATt:ltuL
❑Geothermal "O�(Heating/Cooling SUPPLY) ❑Residential Water Supply(single) ft
❑Industrial/Commercial in.
❑Residential Water Supply(shared) 'Ytt lr1tAUT '• .
' ❑hri scion mince rO - •_. - . .. . .
Non-Water Supply Well: ttIA4TMUL PLA
ft ft jnCEMErrrMErg our
❑Monitoring ❑Recovery ft & ¢ oDtf, ooNf
Injection We1i• 3 U
❑Aquifer Recharge ❑ ft. ft
❑Aquifer Storage andRecovcn f'rt°mtdtaReniediation 39'$A111ti7 +UyptCj�if•..'lilstife
❑Salinity Barrier mtOM To atATEttIAL❑Aquifer Test ft R. EMrIACentEN7.MEtgOD:
❑Stormwatrs Drainage
❑Experimental Technology ❑Subsidence Control &
ft
❑Geothermal(Closed Loop) ❑Tracer C°lots`act r :'Oddisac d'atieees:ifu
❑Geothermal(Heating/CoolingurnoM TO DFsaarrnoN mier hardn z'SUnuk
Ret
p ) OOtha{explain under#2I Remarks ® it ft .:.'nacre ere f
4-Date Well(s)Completed O 3®� g _ Q [— V j6
__g^wel W.# /,S J �� ft ���ya.r s�;
Sa.Wen Location: !� fR �—
-7W9-A, Pfc ft ��it a4(t-I►/
FacahtY/OwncrNanic & ft.
L�`
Facilitq lDt'tifipplicahle)
it ft
Physical Address,Ciry,and Zip ft ft
�,5 t:t9p.¢11 �:;zr:�isE•x�zi�;::: :• •..: ..-::::.:.-' `z`- -., �. .. -.,
County ..3-• ''c--!'...
parcel Identifirabioallo,{PIN} ::::
5b.Latitude and longitude indegreWininutesfsecoodrordecimalaegrees ' -' Ltr=1
(IT-ell field,one laydloag is sntfieieat)
g q ® ® 22•Certification: r;
3 T� N- ? W � ' C�
fr-'b(arc)thewr** �e a' nent. or ❑Temporary d�ofCeaified Well'Gonaae6or
Date
7-Isthis a repair t0 an ezisting.,welL ❑Xes or [})Qp 14 sr15A;N rhlC 02C,!hereby cerrfjy char ue•we4s)war(wera)constructed In accor&nce
wit/r I3i1 ArCdC OIC.Ol00 or 15ANCAC 02C.0200 Well CdrrrlrudRon Mandonds mid thcl o
!f ibis is o rcpalr,frpora.bte wn well conttruclion informolion and 'a?�'O�th!?mnfhar beM now �atherrd owner.
repairanderi`21remarh rionoronthebaekofihLsform. p&nrhenatarrof.ie
j 23.Stte'tyiagisuar or addiffottalwell details:
>3.Number ofwells constructed: [i You tnaY•Usti the ha*of this pave to provide additional well.site details or mobil
For multiple injection or non-warersupply wells OIVLYwIth rhesmne coruducdorr you can eonstiuction details, You may alsti attach additional
submlroneform pages.ifnecessary.
SUOMMALINSTUCTIONS
9-Total well depth below land surface: �d
Formaltiplewellrliuolldepthrifdrocrer*(earnplc_3Q200'and1�L00� (ft) 24a For A11 We1L= Submit this form within 30 days�of completion of well
10.Static water level below top of casing: �.
Ifxaterlevel is above casing,use^+^ (ft) Division of WaterQuality,Information Processing Unit,
1L Borehole diameter. 1617 Mail Service Center,Raleigh,NTC 27699-1617
_ Cn•)
24b For IDieetiou•Wells: In addition to sending the fort to the address in 242
i..Well construction method: above,
(i.e. also sitbit"t a copy of this form within.30 days of completion of well
auge,rosary.rabic,daect push,erz,) construction to the following. i
FOR WATER SUt'PL1'WELLS ONLY: Divisiod of Water Qualify,Underground.Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699_lG6
13a.yield(gpm) Method aftest: 1310,wn20 minute 2'4r-Foi-Water.SDDniy&Iniectiolt Not In additionto sending the form to
13b,Disinfection fie HTH Z"7 tit°addresses)abomr,also submit one!copy of this faun within 30 days of
' AMO O: coIDpietion of well Go.tah;tction to the C'Monty health department
where constructed. trttent of the county
Form GW-1 North Carolina De
partment
i^`^^r^tandNaturalResouces-Dixision,ofwatergmlityt
1 Revised Jan.2013