GW1-2022-09316_Well Construction - GW1_20221006

V�'ELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
I-Well Contractor information:
2At4:WATERZONES. _. I
FROM TWO DRSCR�TION
Well Contractor Name
3 170 � jev ft 4,011
—� /tot` /.-3f7t` •al; 3D�n24fv f NC Well Contractor Certification Number 15 pD rER,CASfNG to c,titnitF.e,sedxrydb OIt.LINLR`if a licitite ,
Barnette Well Drilling, Inc. O"f TO DLAhitiLFR i rllrcTavEss MATERIAL
fc $ ` in /t`/
'Company Name 7G:1Pi1HTi';Cs1SIP1G-0111UAIINGr eottie tnallclosled3oa:
2.Well Construction Permit#: I/t •� T�ROM TO DLAMEI'ER TFIiC[ttVFSg 1NA'TERiAL
List all applicable well construction permits rr C�ty State,4a ance ` ilk
3.Well Use(check well use): ft. fc "'
Water Supply Well:
FROM TO DIAMETER sLOTStZE THIC[QVFSS MATERIAL
❑Agriculhlral, ❑Municipal/Public• fc tt is
❑Geothetrnal(Heating/Cooling Supply) Wtcsldential Water Supply(single) 2 ft. in
❑Industrial/Commercial
❑Residential Water Supply(shared)
❑Irri ation
RROM TO MATERIAL... ... EMPLACEMENT METROD&AMOUNT
Non-Water Stipply Well: rc fc
t
❑Monitoring ❑Recover}, fc t7 cc N
Injection Well; R ft
❑AgtriferRecharge OGmundwaterRemediation -;Is SATtu1GRe[t'gt PAG1C if` Lt tite
❑Aquifer Storage and Recovery ❑Salinity Barrier ItOM TO MATERIAL EMPLAcetxETir.hfETgoD 1
❑Aquifer Test fcft❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control tt rt
OGeothermal(Closed Loop) ❑Tracer :;ZO`bltlGLiflTG`L'OG:aitaati;.0d4it7oaiifshne}s;i[uecessa
❑ FROM TO DESCRIPTION(color.ham :oair"k '•n. ;tea ...Geothermal(Heating/Cooling Retain) ❑Other(e>�lain under#2I Remarks fc ft '
L !!-e
4.Date Well(s)Completed:o'-/ z2wellIm ft
T-0[f (ASQJ N 2( ft
Sa.Well location: S-
PRtr,elg �S
FaciGry/0(livtn ft. rtcrNaide Facility�DP fippliabtE)
�1� �' Shnn�N- � f�- � t` •
Physical Address,City,and tip
rt. it . 2022
County %-
Parcel Identification No.(PIN)
5b.Latitude and Longitude in.degreedmiuutes/secoods or decimal degrees:
Olycll field,one lallong is sufficient) 22•Ctrtification:
N 7 9. . ZG55' C2 � � • I,mac Q� ..ZZ
w
Srtpzarrrcao Well'Contratfior Date.6'Is(are)the well(s): ll3PL'anent. or ❑Te it fCemfied
$y sibrefng lhts form,/hereby cerirJy ihat lbe•well(s)war(were)constructed in accordance
7_is this a repair to an existing;we[l: ❑yam or "'rh IJ� C 02G A100 or 13A NCAC 010 0200 Well CdAS6*rlon Standards oird thus o
If this is a repair,ha autabrowit well construction i onmatian and �PYa Mils!rQ0^ihas been pmvided to{he rrell owner
mpairander..92I remarks section or on the.back o phis orm. arplmn dre nurse ofllte
f. f. 23.Site disgizim or additional weU details:
You tnity'use the back of this pact:to providi:.additional well.site details or well
8..Number oPwells constructed: i onstnretion details. You may also.attach.'additiorial es:if sec
For muklpre injection or non-waver supply wells ONLY with the same construcaan,you can P� estaq.
submit oneform. SUBMITTAL INSTUCTIONS
9.TOW-well depth below land surface: gL) 24s. For All Wells: Submit this.form iwtthia 30 d Form-ltipfe wills[istofl depths rfdo,&rerit(eidmple-3@200.4;d 2 00 aS'S of completion of well
Ql � cdnstittetion to�the'foliowing:
10.Static water level below top of casing: ({�) Division of Water Quality,Iniformation Processing Unit,
Ifw�arer lewd is above casing,use"+" 16V Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: fin,) 24b.For Iniection•Wells: rn addition to sending the fort to the address in 24a
above,also submit a copy of this forth wi
12thin 30 days of completion of well
Well construction method: construction to the following-
(.e:auoger,rotary.-h1c,d r-push,
Division of Water Quality,Uudergrl und.injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cente,Raleigh,NC 17699-16U
I3a.Yield(gpm) Method oftest Blown20 minutes 24c For Watet.Supift&Infection Wells• In addition to sending the-form to
Ol0 Z.- the address(es)above,.also submit one copy of this foim Within 30 days of
13L Disinfection type: 1'I�1'1 Amount: completion of well construction to the county health department of the county
where constructed.
Forth GW-i North Carolina Department ofFnvirooment and Natural Resources-Division ofwa(er li
� tY Revised Jan,2013