GW1-2022-09319_Well Construction - GW1_20221006

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For internal Use ONLY:
L Well Coniractor Information:
V O Af/!li �•f t�'0' Ld:WeiTER Z()N>S. 1
FROM
Well Contractor Name /6-6 TO DESCRIPTION ft � ft
2lo rt z2d rt 4�ra l �1[� y�o t5 NC Well Contractor Certification Number L OUTEit.CetS1PIG for.:tindtltased.rveUs.OR LWER'ita liratile
Barnette Well Drilling, Inc. FROM TO ft OLIMEIFRtQ� MATERIAL
Company Name
lb.1N1�71rIC,CAStIV�UR'i'DBWCr';'eotlieti5_al.c[ostdloo'
2.Well Construction Permit Al2 r FROM To DMmILMIC THICKNE$3 MA'TERiAL
List a/1 applicable"ell construction perms(i.G Cmmry,Score Variance,etc)
3.Well Use(check well use): ft ft hL
7Z.SCRPEN:'
Water Supply Well: I?Ri/M TO DIAMETER SLOTSIZE THICKNESS AfATEttIAL
❑Agricultural ❑MunicipaUPublic• M ft in.
❑Geothermal(Heating/Cooling Supply) ORrsidential Water Supply(single) ft ft in.
Olndustrial/Commercial tia ~Y&GROUT'
❑Residenl Water Supply(shaiEd)
Olrri $lion IrItOM TO
Ft ft t1fATERLIL �r C METROD'&AMOUNT
Non-Water Stipply Well: OUf
t
❑Monitoring ❑Recovery ft D fr.
Injection Well_ fL R
❑Aquifer Recharge OCrooadtvaterRemediation 19'SA't /GlsttLTl+lGBrti iC if i;i hte ;.. .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft TO MATERIAL F1tiPI.kCt MFNT.1\IETHOA
❑Aquifer Test' ❑Stonnwater Drainage
fL
❑Experimental Technology ❑Subsidence Control ft fL
OGeOUtetmal(Closed Loop) OTracer :;ZIi 11RIGLiAIG`1 00:attniti:d3ifi"*fihLtJ r71iec isa
I FROM TO DFSCRIPITON ulor,hardnreirnek ,•n.oae:ere..
❑Geothermal(Heating/CoolingyRetuin) OOther(e)q laiu under#21 Remarks ft ft V e R Q fZ f
4.Date WeIi(s);Complcted o"�6 We1l'ID# 1-5Z J,(kl J it
Sa.Well Location: �) G�Z`t j sit -ago a-,,—
ft 6 ft A
Col/r'it�S�%p/lcv (�r?o,Pdlf,�s � W C.�
Facility/owner Name Fadility 1Df(if appliatite) ft
fL
physical Address,City,and Zip & ft
SP77M 17` -
County Parcel Identification No.(PIN) j
5b.latitude and Longitude in degrets/minptes/secondsor 4eamatl degrees- V n;4
(Nvcufield,one 120o • 22.Certification: `."' Vtiv+ i
ng u sufficient) � -
36 - N Z sc-?7w � rr ��
Sign?unaoft:emfied 11.luntraetor Date
6'Ls'(are)the tvell(s): aPermanen't. or OTemporary
8y sr�rrfng.tbfs farm,I hereby certify that the well(s)war(were)constructed in accordance
7.Is this-st repair to an existin ,well: with 15A•NCAC 02C.0100 or I5ANCAC 01C.0200'F7dl Comiiucaah Srondanis aid tho o
existing..well: or B*u-- sopyvfthirrec»rdharbeenprvWdedto-thewellowner
If flits is a repair,fill ourlarown well construction information gVrdecplirfn the nature offhe
repairrtnder?121 remarks section or on rhe.backofthi3 form. 23.5ite di$gtam or additional Well details:
8.Number of wells constructed:
6 You tray us6 the back of.this pave to provide.additional well.site details or well
constnrction details. You may also.attach additional For multiple iryecrion or non-water supply wells ONLYw Ihthe same eoni*nelian,you can Y pages:if necessary.
submitoneform. I SUBMITTALLNSTUCI'IONS
9.Total well depth below]And surface.- 4 r (,y
For multiple—Us 1is1o11 depd.,fdf�ererrt(e),m"ple-3@200'andl O0 (ft) Via. For A Wal lt ls: Submit Ih;s.Sottn tinihin 30 days of completion of well
Q construction totht fhllowig:
10.Static water level below top of casing: Ti ( ) Division of W at"uauty,Information Processing Unit,
Ifwater level is above casing,use"/+" 1617 Mail Service.Center,Raleigh,NC 276994617
11.Borebole diameter. p !
fin) 24b_For Infection.Wells: In addition to sending the form to the address in 24a
12.Well construction
above,also submit a copy of this fonii within 30 days of completion of well
(i.e.auger.rotary,cablels., method:direct push,etc.)aiconstruction to the following.
Division of Water Quality,Underground.Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I3a.Yield(gpm) f Method oftest Blown20 minute 24e Fg`WAtei•.Suouly&Infection W'Its• In addition to sending the form to
HTH �tsdZ,�w the addresses)above,also submit one copy of this f0im within 30 days of
136.Disinfection type: Amount •' completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department ofEnvimnmont and Natural Resources-Divisionof Water Qualityr Re
vised Jan.2013
.f