GW1-2022-09333_Well Construction - GW1_20221007

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WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
I.Well Contractor Information:
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DESCRH TION Well Contractor TOactor Name
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NC Well Contractor Certification Number Ifi 0I1TElI.GAS1AtG.foc,tudii-�tiQ', .e![s.OR LiNER'rfa liable
Barnette Well Drilling, Inc. oM TO DLIME3FR rlHtraaess MATERIAL
Corr4auy Name 1b.:ItdlYCg;L`i►uyti OR'. BlI `eotlieFtiial.closed4"
2.Well Construction Permit#:_ 7 � RROM TO DLAMETER TIIICKNEss MATEItiAt
List a/1 applicable rrrll construction permits(i.e.Counry,State Valance,etc.) ft i0.
3.Well Use(check well use):
Water Supply Well: 1Z:SGR£EI T
CAM TO DIAMETER . SLOTSIZE THICKNESS MATERIAL
[.Non-W2ter
Agricultural; ❑MunicipaVPublic- tt ft. in.
Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R ft in
Industrial/Commercial
❑Residential Water Supply(shared)
Irri anon >ntoM ft TO ft punt-L OUrCEMEN7 MEfHOD'QcAMOUNT
Supply Well:Monitoring ' ORecovery O tt ft
Injection Wcil'- ft ft
❑Aquifer Recharge ❑GroundwaterRem6diation7-7
;'SAlslfl)GlitVltl>PAC1 t ' hi�bte:,..
❑Aquifer Storage and Recovem OSalinity Barrier FROM ft TO MATERIAL ES1fPLACEMENiMETHOD
❑Aquifer Test OStortrwater Drainage
❑Erperimentat Technology ❑Subsidence Control ft ft
OGeothermal(Closed Loop) OTracer
ZU bGLiIY�'d O :2itac6'�dais;fuiif:stteefs italcessa :::.::.. ... .:
❑Gmth-mal(Eieating/CoolingRetum) ❑0ther(explain under#21Remarks) FROM ft. To
To DESCRrpTiON eolary•hdn sdiVI nc7redc
4.Date Witt(s)Completed ��L"ZZWell7D# t` ft C-t�• fj�y�(j s
Sa. ell Location:
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Facilitylown"Name ft. fit.Facility IDI:(if appliatilb)
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Fhysi Address,City,and Zip fit.
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County
Parcel ideruificatioallo.(PINT)
Sb.Latitude and Longitude in d I t,f egrets/minptestuconds:or decimal degrees:
0,urctl field,one III is sufficient) 22 Certification:
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6 Is are the wells: $chalice o Cattrfied Well Contractor Darr fare) () aperlfanent. or ❑Temporary
By slgafngibrs form,I hereby eerrify chat the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0f00 or ISA'NCAC 02C.0200'Wdi Construcdbh Slandorias 4od.t/rnt.a
7.Is tbis•a repair to an cxisting:well: OXes or C�fe•�'
t4Y° i recnrdharbeen pr»rided ia-lhe well ownerf!Iisisarepolr,flout bownwellcarauucriont information a'd�b'n dru naturerrpairuader21 remksetionoronihe. ackofihliform. of-the
233.Site diiagiI or additibrial well details:
&.Number of we11s constructed: You n'ixy use the back of this page to provide additional well.site details or well
For multiple injection or non-roarer supply wefts ONLY with the Same construction,you can COhstnrcfion details. You may slsti.attach additional pages:if necessary.
submitoneform. ,( LIEMMALINSTUC IONS
9.Totat'we11 depth below land surface: U ?,Q (ft) 24a. For Ail W..elis Submit this fa. rm within 30
For rimdriple ioeOs lisrall depths irdecrent(—;Wple-3(a3200'artd 2 00 days of completion of well
C� � construction tothc foliowiitg:
10.Static Water level below top of casing: —IP6 Division of Water Qnal;ty,Information Processing Unit,
Ifueler level.is above casing,use"+" ( )
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ells: In addition to sending the form to the address in 24a
fin•) 24b.For IniectioD•W
12.Well construction method:
above,also submit a copy of this form within 30 days of completion of well
construction to the following.
(ic au.—,rotary,cable,creek push etc.) �
Division of Water Quality,Undergroand.Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 17690-1636
13a.Yield(gpm) 11I'ethod offal Blown20 minute 24e yorW6 er.SuDoly&Inieetioh Webs In addition to sending the.form to
�.r.H �D.- Ilse addresses)above,also submit one copy of this form within 30 days of
136.Disinfection type: Amount p completion of well construction to the'county health department of the county
where constricted.
Form GW-1 North Carolina Department ofEnvaunment and Natural Resources—Division of Water li
h i Revised Jan:2013