GW1-2022-09317_Well Construction - GW1_20221006

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Intetoal Use ONLY:
I-Well Contractor Information:
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q?ATER Z DNES.
FROM To DESCRQ17ON
Well Contractor Name f40� ft
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60 ft NC Well ContractorCertifiation Number •1 R:EAS@lG tor.►nalli ratid7Ydls.OR IdN1+RTO
'if a lidtile' ..
Barnette Well Drilling, Inc. I�toM ft �fL DL4ME�CFRZO_ ASS: MATERIAL
Company Name 6,14f, - r(�
1G.11T1`ICIC:CAS1iVCr ORTG IN(> `eottie•rval.cto#edd
2_Well Construction Permit#:_Y."y/ Z LQJ�'��n ItROM TO DL4MECER TutcHNESS MATERIAL
Lis'all applicable Nrll construction permits(i.e.County,Slate,V,,Queer et f rt tL to
3.Well Use(ebeck well use): r"
Water Supply Well: F"N1 TO DNMET£R SLOTSCLE THICTQVESS \lATERiAL
OAgricultural; ❑ldunicipalftblic• rk ft in
❑Geothermal(Heating/Cooling Supply) aRiffldential Water Supply(single) fk rt in
Olndtrstrial/Commercial O.Residential Water Supply(shared) YS GItOUI'
' OErrigation g��(
FROM To MATERIAL. EMPLAC0WW-.MERtOD&AMODNr
Non-Water Supply Well: . rt ft Cwnent our
OMonitoring ORecovety C> ft 0 ft e�/VL
Injection Weil': iL ti
OAquiferReeharge OGmundwaterRemediation YSs'SATFflI ReI I'I'A 3lC it' Li�tite
OAquifdr Storage and Recoven, OSalinity Barrier FAOM To MATEitIAL Fniri tcentEair.nfelgop
OS
OA uiferTest ft ft
q tormwater Drainage
❑Experimental.Technology ❑Subsidence Control ik R
26 bR1GL9NG'LOT' :ti edt7i6
❑Geothermal(Closed Loop) OTracer .isiifai 66*1" slt_ _ �.. ,..e. ..
ets:rrdlcfssa
FROM TO
OGeotbamal DESQtIPTION colorhartln 'Zplhroek •nr+�.eti ..
{lieating/CoolingRetum) OOther(er�Iaiuuniler#2lRemarks d ft 6 ft D 1J a�
4.Date Rrelt(s).Compicted We11 ID# .3�J jN fk ft A-
sa.Well Location: �Z` 3-,!"ft /u S hht3ls
Facility/Owner Name
Facility IDf:(if' Bali')
Physical Addrreessss,City,and Zi p ft ft
-1�/r LT2 C p� 0 b63 [ �j/�/!�- 2l:.kE1GbI;ICS'.
County Parcel Tdcat ficatioo Nn.(PIN)
5b.Latitude and Longitude in.degrees/minptes/secoudsor decimal degrees: linii
({Ewell field,one laNtong is sufficient) 22.Certificatibil:
6'Is'(8re)'the wall(s):t�!'ermanent, or OTeurporary SrgaatureofCetnfied W&C-Ontratxor Date
AY slkning.ihis form.I hereby eerfrfy that the well(s)was(were)constructed in accordance
7_TS this a repai with i3A NCAC 02C.0100 or I5A NCAC 02C.0200'Wel/Constrrteribh Standards mid chum
If this is a repair,fir to an cxisting.,welL• OXes or 6�Po ll out known well construction information urtarspl6in the nanrre.oJ the aopyofthir rernrrfhar been prnvlded to the sl'ell owner.
revairunder 1Zr remarkr section or on the.back of this form. 23.Site di$gt$nt or a'dditiorial Well details:
�l You may use the back of.this page to provide additional well.site details or well
&.Number of WcBs constructs& cF— cofls nation details, You may Wsd.attach.additional pages.ifnecessar
For muhipre infection or non-waver supply wens ONLywith the same construcfan,you can .
submironeform. SZ1FM (71ALINSTUCTIONS
9.Total well depth below land surface: 6 d ((�) 242. For All Wells: Submit this.form th;n 30 d` Formutiiplewerlslistalldeprhsifdijferenrro mple-3@200'and 2 00 aysofcoinplebonofwell
QI � constitretion tbffi'e'fo'tiowiirg:
10.Static water level below top of casing Z ( ) Division of Water Quality,Information Processing Unit lfNvtei level is above casing,use":' 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: ♦j fin,) 24b-For Inice ou.Wells: in additionito sending the form to the address in 24a
2 pD_/��� above,also:96bnrit a copy of this form within 30 days of completion of well
12.Well construction method: I iC T construction to the following:
(.a auger,mtary.cattle,direct push,etc.)
Division of Water Quality,Uuderground.Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 16M Mail Service Center,Raleigh,NC 27699-16%
13a.Yield(gpm) 6 Method o'ftest Blown20 minutes 24e FOrWater.Supi)IV gr Inieetion Wdis- In additionto sending tbeform to
the addtcss(es)above,also submit one copy of this form within 30 days of
13b.Disinfection type: I'ITI'I A completion of well coirshUction to'thel cdttuty health department of the county
where constructed.
Form GW-1 North Carolina Department afFavittnuneat and Natural Resources-Division of Water
Qa h'ty Revised Tan,2013