GW1-2022-09341_Well Construction - GW1_20221007

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WELL COI+TSTRUCTIOAT RECORD 4
This form can be used for single or multiple wells For Internal Use ONLY:
1.Wel ntractor Information:
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WQO Contractor Narne FROM 710 DESCnWtION
� 3 75ft Sa rt-
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NC Well Contractor Ccrti6eation N /.!O ft zc^d5 OT1TEFt.eA.S11`tG for kind', 5
Barnette Well Drilling, Once t4'MLTM [s oTMCF(NFM a urMAT
FROM lYr DLIMETF1t i 1WCtOVFSS MATP1t7Ar,
Company Name a MLY1K:Cx>uS1NG•0OltTUBING
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efmal.dac�d3" "
2.Well Construction Permit a: 111"' ��- A[nMErFR 7ittC[QyE,4g MATFBi�L
Llsr all applicable Knit construction ft ft is permru(te.Cmnrry.SIOIq Yorionce,etc.)
3.Well Use(check well use): ft ft in
Water Supply Wdl: ^1Z:SCRiiENl:'
OAgricultulal
FROM TO DIAMETER SLOTSIZE THICRNFSs ltATERUL
OMunicipal/Public• ft. & in.
❑Geothermal(Heating/Cooling Supply) 099d—ential Water Supply(single) ft R in.
Olndustnal/Commercial ❑Residential Water supply(shared) y8<Gftl3UT
Olin ation FROM TO MA4ERLIL EMPLACp1fFKt------D&AMOt1Ni
Non-Water Supply Well: ft ft Our
❑Monitoring
Injectionell':
OReeovery g ft Zs& e /►dy W
ft R
❑Aquifer Recharge OGmandwaterReniediationVU1K?.lgc'S9I(ti/Gls1;PAC if" ueybje
OAquifer Storage and Recovcry OSalinity Barrier FltoM to MATFRIAI
ft FMPLACFMETif.MET$OA
❑Aquifer Test ❑Stormwater Drainage
OExperimental Technology OSubsidence Control ft ft
13Ge4thetmal(Closed Loop) ❑Tracer :2U 21 L�I+IG`ivOG.:aitacV-2-ciioniif-s'eeLs.ifu669m
OGeothe[mal(Heating/COoling Relum) ❑Other FROM TO DESCRIPTION color 6ardn soithock"
(explain under#21 R.emarks o ft ft '°-A"`t`.
4.Date Wel!(s)Completed-- �6- ft ft
p �._._�Vell rn# ems.: }}
Sa.Well Location: & Oft /'
G/
fk 21 eft 6 0
FaeiGty/QivnerNanie ft ft
e�p, J FaEility MP(ifapplieablb)
�r ft
Pkysteal Address,City,and Zip fk ft
^ � :;2r:•:iil�ilrules":� ;:':.:":,i..:;•:::-;:::.:,-::.: -•
County Patrol Tdentifiaboo No.(PIN)
56.Latitude and Longitude in degreWinjuutes/secubdsur decimal ilegree3:(rftveu field,one hoong is sufficient) 22.Certificatibc: .
3GL6i N 7y.
6:'Ls'(are)'the WAI(s): anent. or l]Tetio Srgnatarcv tl�r Date V G L2
po�3' By sr'$nrng.ihfs farm,I hereby terrify char'he'ivell(s)war(were)constructed in accordance
7-Is this.a.repair to an existing."well: ❑Yes or L91iFer with•ISJf"i9 reco02C.OJi70 or l3it NCAC 02C:0200 Well Copuirricdoh&andards mid tat a
if iAis is a repot,fill out known well contraction hJbrmaGon mrd• cO °�"s�fo"ihas"betn provided to the rrdl owner.
repairrtnderf2l remarlx section oron the.backofihls form, espT<rra the nmur'.0
23.Site diagi in or add itibdalweU details:
d You tnay'use flit back Of this page to pr6wdb additional weal.site details or well
faNumber of wells•rna- arerconstructed: bobshucxion details. You may also.aittaeh additional
For muhiple injection ornon-watersupply wells ONLYwtrh thesame eonstracifan,you can pageS.if netxssary.
submuoneform. S11D1►MIT1CAL1NS1UCT10NS
9.Total wdl depth below land surface: Z
1%orRndVewellslistalldepd.ifdgrerit(�rple-3Q200'andl 00 (fry tea. For An We]Isti Submit this fi)nn 4thin 30 days of completion of well
2 � 3 cdarstiuetidutriYhef6llowing:
10.Static water level below top of rasing: 5_ ( ) Division of Water yvaur level Is above casing.use"+" Quality+Information Processing Unit,
G 16b7 Mail Service Center,Raleigh,NC 27699-1617
IL Borehole diameter. (im) 24b.For In! ation.Wells: En addition to sending the fort to the address is 24a
Above,also Subrmt a copy of this f 12.Well construction method: ora;withiD 30 days of completion of well
l�t� p f'/�RY
(L canshubtiontothefollowing:
e.eUge�rOWry.able,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY-
Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 17699-1636
13a.Yield(gpm) Method oftest: Biovvn20 minutes 24e Fat water.SnoDly&Iniet'tion E9!s•'In addition to sending the.fonn to
�TH TroZ the addresses)above,also submit one copy of this form Within 30 days of
136.Disinfection type tiveo compaction of well constrtction to the county health department of the county
where constructed. f
Form GW-1 i Nonh Carolina D cpadmeat ofE"&0mxnt and Natural Resources-Division of Water tZoality s Revised Jan.2013