GW1-2022-09388_Well Construction - GW1_20221007

WELL CONSTRUCTION RECORD
This form can be rued for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information S
ipilON Well Contractor Nam FROM e Oft TO DPSt�t
7-2. ft
3/o ft
NC Well Contractor Certification Number da OBTE[t:GA51(!iG fob;titniti eased;jcells.OR L1NER`if a',liaftile
Barnette Well Drilling, Inc. `°M T° D""' ` "rr MATS
D ft PC5 ft : ! �a aZ 2 c
Company Name 7b lfl(VEIF;CASIIVU Uit'FOBING'<.'`eotGertual.closedd
2.Well Construction Permit4: � xROM TO DLAMEFER THLC[QVES3 M1rg[
List all applicable'ell construction pern gs(r.e.Ctnmty,Slate,Irariance,etG) a
3.Well Use(check well use): ft.
R rrt
WaterSapply Welt: :'1Z:SG1tBEIQ:' .. .
PROM TO DIAMETER SLOTSUF THICKNFSS AtATERtAL
❑Agricultural OMunicipal/Public• ft in
❑Geothermal(Heating/Cooling Supply) &gc—sidential Water Supply(single) ft ft in
OlndustriaUCommercial '
❑Residential Water Supply(shared)
❑lrri ation FROM TO MATERIAL. 1?INPWCPMENT METHOD&AMODNT
NO ter Stipply Well: ft ft 9t ourecl
❑Monitoring ORecovery ft Z 0 fr-
injection Recharge
OGroun'dwater Retnediation Y9`SAjWDjGltA 4gE1.JPiq+CjEC;f °Ui�tiie
1-
ft. f
❑Aquifer Recharge - ���
❑Aquifer Storage and Recovery ❑Salinity Barrier ;:FROM ft To MATERIAL EMPiACFM©PJ nteraOA
❑Aquifer Test OStormwater Drainage fL
❑Experimental Technology ❑Subsidence Control ft ft
OGettthermal(Closed Loop) OTracer :2U;Il L9NC°1UG_:aifaia;; ddiSuosrskee7s:ifuizesa
77777777777
❑Geothermal(Heating/CoefingReturn) ❑Other(explain under#21 ft Retnarks EOM TO DFSCItIpTiON tolor,hudn soit/roek n ��
ft D
4.Date Welt(s);Complcted �' r 11 '� ft 2-2—ft
e
Sa.�Wyell Location: f {JJ�sE3i lQ
V h JP.i f}y /eJ�/t'� Q .'C Jl
FacilitylOivtrerName "]-- FacilikkM?Gfdpplieablb)
i
I'Irystral ft ft.Address,City.and Zrp
r.ztE•-n3rAlucs';;;::::,: ::..:::.:;:: -;:;: : :.:
2 2�
County Parcel Identificadoa No.-(PM
5b.Latitude and Longitude in.degrees/minutestsecondrbrdecima�l'degrets:
(tfwell field,one lattlong is sufficient) 22.Certification;
r SigaauveofCct ied Well'Cinttattor Date.
Ls(are)the well(sj: rntanent. or OTtinporary
$y sf&tngAls form.1 hereby eerrify that the-weQ(s)was(were)constructed in,accordancd
7.Is this a repair to an existing well: ❑Yts or ID2do wrth 15A NCAC 02C.0100 or 13A NCAC 02C S200'lfell Consiruciloh Standards and thoi.o
If(his is a repatr,fillouabrown wellconstrucrion information and:eg"n die nature ofthr copyof t/{h recordhrtrbeur provided ta the well owner.
repairnnder921remarkr section oron the.back ofihlsform. 23.Site diagt*mof additional Walldttails:
�/ You may use die baclt of this pave to providb additional well.site details or well
&Numberofwellsconstructed: b6listnrcdondetails, You mayalso.attach additional pages,ifnecessary.
For multiple iyecrron or non-water supply wefts ONLY with the amne eonstruciFaa,you ran
submitonejorm. SUONWAL WTUCTIONS
9.Totai'well depth below land surface: T/2 (ft) 242. For All Wells; Submit this.form within 30 days of completion of well
Aar maltWe wells UsIo11depduifdifferent(er0MP1e-3Q200'annddZ(W00J consductiOnYbYlre'f011dWing:
10.Static water revel below top of casing: �S (ft) Division of Water Quality,Information Processing Unit,
Jfw titer level is above casing,use"+ 1617 Mail Service-Center,Raleigh,NC 27699-1617
i
1L BoreholL-diameter: fin:,) 24b..For Iniectibn Wells: In addition to;scnding the form to the address in 24a
Above,also submit a copy of this form within 30 days of completion of well
12.Well construction method: TL�2`7� canstruction to the following.
('i.c auser.rotary,cable.d¢ectpusfS etc.) --ram
Division of Water Quality,Underground.Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ceuter,Raleigh,NC 176994636
13a.Yield.(gpm) ./ Method oftest Biown20 minute 24s Fok-WV itei•.Suni)ly&Infection Wells: In addition to sending the form to
136.Disinfection type: HTH A find addtess(es)above;also subdiit one copy of this foim within 30 days of
mo completion of well construction to the county health department of the oounty
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water l 4
�r.ty Revised Jan:2013