GW1-2022-09390_Well Construction - GW1_20221007

i
A
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
L.Well Contractor Information:
Id: 'Ei1ER.Zt)NES. {
FROM TO DESCRUMON
Well Contractor Name
ft 2�ft '�
6a ft
Contractor Certific N
NC Well ation umber Z-V&ft. `
15 p11 PER;CA5Il?iG ior.:toddti casedveJjs.OR I JNER`if a Iictitile .,
Barnette Well Drilling, Inc. FROM DLAiHE1FR THICK11114 MATERIAL
Company Name
..7t.1NPiGltt;xl;StiV -01t•'I'OBING':.''eotliefrrual.eloSed� ..
2.Well Construction Permit tl: 156 FROM TO DIAMETER THiCKrffM ]yATERiAL
List all appllcabta xell construction permits(f.e.County"Stote Irarfance,ere.) f t R is
3.Well Use(check well use): f tt "-
Water Supply Well: 17::SGR)E11T:':
RRDM TO DIAMETER SLOTfihZE THICKNESS %TATERIAL
Agricultural', ❑Municipal/Public- ft ft is
❑Geothennal(Heating/Cooling Supply) ential Water Supply(single) 2 ft in.
❑IndtrstriaUCommercial MATERIAL
❑.Residential Water Supply(shared) :18 GItOT1T:
::.
❑Irri ation FROM TO EMPLACEMENT METIiOD'&AMOONT
Non-Water Supply Well: ft ft ourea
u,� nt'
❑Monitoring ❑Recovery ft. ft Injection Weitz &
❑AQuifhr Recharge ❑Gtoundivater Reniediation Is'SALY /G1Yel"uJEL:JPi1G1fr f :tittile
❑Aquifer Storage and Recoven, ❑Salinity Barrier FROM ft TO MATERIAL rltCeniEari.ntETaon
❑Aquifer Test. ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft rt
❑Gebthefmal(closed Loop) ❑Tracer ucbtalieets:it:ZU;'k►RI1;LIlYG°1;OG:setiiili;2Bdi ulcessa
>HItoM To ;
❑Geothermal g/ g ) DESptIPlION mler 6ardn soil/ k. .....'Zr2'V meta
(Lieatin Coolin Return ❑0ther(explainunder#21 Remarks ft �' ft ��
I
4.Date Well(s),Completed t7`22'?`�jgrep' ® S ft z"Z..ft 9 1e
Sa.Well Location: Z Z ft 10-0t lVor
Facility/OwncrNaine & ft
Facility lDR.(ifapplieable)
ft �.
MWsi .Address,City,and Zip ft.
.
7- -
. .... . .. ......... .......
County
Parcel Identification-No.(PIN) L
.. -r
5b.Latitude and Longitude in.degrees/miaptes/seco ods or decimal degrees:
Owell field,one lot/long is sufficient) -Certification:
l7 N
s2 2
6'Is'(art)'NrcwtA(S): Sr
l3Permanent. or ❑Temporary GOfCem5erl Well'Cannactor
Date
ay s1)V7fHg this form,l hereby cedify that the wells)was(were)constructed in accordance
7.Is this.a repair to an existing well: OXes or wilk 15A�C 02C.0100 or 15A NCAC 02C.0200 Well Construction Srandorrls mid..da;f.a
co
Jfthis is a repair,fill out known well construction in
formation arrd pyoft/ifs reeordhru been provided to the well owner.
,=P1 fn die nature ofthe
repairunderd2l remarks section or on the back ofrhl3fornr. 23.Site diaginm of addifiondwen details:
You mky'use the ha*of this pave to provide additional well.site details or well
8.,NDmberofwellarnorr- atersu Construction details. You may also.attaeh.additional For multiple f yecrfon ornon-irarersvpply wells ONL wtt)i the same coftitracGon,you can y Page,S.if necessary.
submftoneform. SU IVII2TALWgUCTIONS
9.Total well depth below landsntface: g 0if- 24a. For All Wells: 'Submit this.fotm within 3O days of completioh of well
I'ormultiplewe0slistafldepthsffdlffeterit(er4onple_3(a3Z00'andZ W
t ) construction to'th'e following:
10.Static water level below top of casing: (ft) Division of Water Quality,Information Processing Unit,
lfwafer level.ts above casing,use";,^ 1617 Misit Setviee Center;'Raleigh,NC 27699-1617
11.Borehole diameter: fin) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12
above,also subnrit a copy of this form,within 3O days of completion of well
Well construction method: canstrut#ion to the following.
(.M an.—,meaty, direct push,etc.)
FOR I)kOsiod of Water Quality,Unde iound.Injecdon Control Program,
'WELTER SUPPLI'WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
I3a.Yield(gpm) Method oftest: Blown20 minute 24r-For Water.Sabi&A Injection Wells:'In addition to sending the form to
H'.H A 0 tire ad&cw(es)above,also submit one 'copy of this form Within 30 days of
13b.Disinfection type: Amount COmpl�on of well construction to'the c uitty health department of the county
where constructed.
I
Form GW-1 North Carolina Depacfineat of Environment and Natural Resources-Division of Water It
��ty Revised Jan,2013