GW1-2022-09338_Well Construction - GW1_20221007

WELL CONSTRUCTION RECORD
t This form can 6e used for single or multiple wells For Intetoal Use ONLY:
1.Well C ntractor Information: I
( Cl 14.WeITEItZONES �
WdH Contractor Name
FROM TO DLSC$<PffOP7
33 /6 _ q S ft !O ft G®� ez
1 f
NC Well ConnactorCertification Number I�Q ft l ft 0.571
A1
id'0VTRR•CAS11"iG fort®IAtasid�ve1ls OR••IMR'tfa [;white ,.Barnette Well Drilling, Onca 0OM � DL4METet TtacTavrs� MA L
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Company Name
�qy ..Y•G:.A�l1Yl.I2,GA;Suvu-Ott'7'DBIN<'r eottte>-tual.e[osed-l"
2-Well Construction Permitll: /� 7 RROM TO niAMEIFB
List a//applicable xr!/eoasrruaion permits f—e.C-fnunry,Slane Variance,etaJ ft RCTL
in
3.Well Use(check well use): &
Water Supply Well: IT 5CR$gr(:`
PRDM TO DIAME[ER SLOTSIZE TiJiC(t1VFSS LItATERiAL
OAgrimdtural. OMunicipal/Pablic• ft R i�
OGeothermal(Heating/Cooling Supply) LtlR�al Water Supply sin le PP Y( P, ) it is
0 dustrial/Commercial ❑Residential..WaterSupply(shared)
:�is:citoiu.T '.. .. .
Olin at
RROM rO hfATERIAL
Non-Water$u EMPLAC2MENTMElFtOD'6 AMOOtYr
Pply Welt: (� R ft �Rd/ our
OMonitoring mesa
❑Recovery ft 6s fc
lUjection WeIL• �r7 tl,Q elk,OAquifer Recharge R &
OGroun'dwaterl2erriediation 19c'SAlYD1GR14Vk';:IP;#iCIC if
❑Salinity Barrier To ' `Gt$tile
❑Aquifer Storage and Recoven, F110M MATS. mirracenirarr.Mer�on
❑Aquifer Test ❑Stotmwater ft ft
Drainage
❑Experimental Technology ❑Subsidence Control ft R
1OGeothetm8l(Closed Loop) ❑Tracer :Ztl Il12Il;Lil+td#;O& aitacli: ddisduiitatierits:itaazetea
13CTCOthermal(Rentin.fr.oi;.-n-(--) OOther FROM DESCRIPITON eoier hardn soii/roek'
^7 {explain under#2I Remarks ft ft o V - 'nee ere
4.Date Wefi(s)Completed- ft 6 ,tk
Zit
Sa.Well Location: Z2&
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Factlt /
,¢.,a
Fadility ID
+�tyOwncrNarrie lib
_L 3�� �r`� f!(ifippa F ...n. ., .
Physical A s City,and Zip t .+ rc I
�S d� Z t� 7 �2r:•:�lGliililrs:?.:. •_• .0 � ;:..::
County _ -
PamdidencatiooNo.(PIN) ll 3i. ,- ,. a
titi !`;. : . .. • .r llr,,.
Sb.Latitude and Longitude in degreeslminptes/secoudsor decimal aegrets. ,•�,,�� ;
(d'trell field,one lamong is sufficient) 32.Cet3ifiaAtibit:
6 ZISI �✓
/-2 Z.
6.'Is(are) bcwrX(s): awirrmanent. or OTetn o §ignatrneofCdnSecj Well Contractor bate P am.. By sr�rrfn9AFs farm,I here
7_Is is a a repair to an existin ;well: W&13J1•NCtC 02C.0100 nr I�NCAC 02G.OZhx the. �� /Cdn,udtj0h Yandv ac off�tQ
existing.,well: or M o�
If this/s a repair,fill out brown well conrtrwrion information card -pychhIs 1 eroFhos•been provided to the well awmer.
repairuader+r'21rwwrkssecrionoron.1he.bae,¢ofildsform. �101adianatirr�ojihr
23.Si&&jgfam or additioudwell details:
8,Number ofwells constructed:_ ' You tray use the bade of this pogo to provide additional well.site details or well
For multiple injection ninon-water supply wells ONLI'wtth the same eonstracira cotlstruc don details. You uiay alsd.atlach additional pages-if necessary.
submitoneform.
N.you can
SUBAIMALINSTUCTiONS
9_TotafweR depth below land surface:
Formultiph weUslisnapdepdu/jdifferrrit fezample-3(a�200 and7�1009 (ft) 24a. For All Wells Submit this form wthin 30 days of completion of well
nstiucddn toffiefolidwiitg:
10.Static water level below top of casing: 7 s^
If—terkwJ is above casing,use^+^ (fk) Division of WaterQuality,Information Processing Unit,
1L Borehole diameter
161.7 Mail Service.Center,Raleigh,NC 27699-I:617
: (in-)
246.For Inieetion.Rells: In Addition to sending the form to the address in 24a
12.Well construction method: above,also stibmit a copy of this fours within.30 days of completion of well
(i.c augc,mta:y,cable,direct push,etc.) cmitt(uction to the following.
FOR WATER SUPPLY WELIS ONLY: Divisiod of Water Quality,UndcrgIround Fnjection Control Program,
1636 WWI Service Center,Raleigh,NC 27699-16M
I3a Yield(gpm) 131otnrn20 miltute Toe For stei.Saoniy&Iniectioh Welts• I i addition to sending the form to
Method oftesk
[ TH S"D the addiess(as)above,also submit one�eopy of this form within 30 days of
13b.Disinfection type: Amount �l "l n completion of well construction to the county health department of the county
where constructed. If
Form OW-1 North Carolina D eparhneot of Fwiroament wad Natural Resauroes-Division of water Quality f Revised Jan.2013