GW1-2022-09392_Well Construction - GW1_20221007

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WELL CONSTRUCTION RECORD
[his form can be used for single or multiple wells For Internal Use ONLY:
I.Well ontractor Information:
Well Contractor Name FROM To DESCR�TION
3.3 -2ol
ao�fL b t�
NC Well Contractor Cerdffleaation Number MI5.• 11TER.CASING for mnl-•
Barnette �0� Drilling, Inc. �v�is ORLIIXER'tfs tidtile ..
FROM TO DL4ME[F2r
'® I TfQCrtN&SSM/A�TFRiAL
Company Name 2- fL y m "-al 1 v�
C./ FELON
I6.t A�SIlV6.01tTO efmoldddidl'
2.Well Construction Permitii:_ DiAMEtFR TIirCIQl[+Sg MATae�rar
List all applicable veil construction petmtts(i.e.Cmmry,Slate,Irarionce,etc) ft R to
3.Well Use(check well use): ft in
Water Supply Wdl: 7Z SG1tgEN."
trRbM TO DUN SLOTStZE MUCKNESS 9tATERiAL
❑Agriculduai ❑❑M�n�ic pal/Public- ft in
❑Geothermal(Heating)Cooling Supply) Elk6dential Waters 1 ft
(single)sin le fc in
❑Industrial/Commercial Supply )
❑Residential Water Supply(shared) dg<GitAIUT '.'.
❑hn anon FROM i0 MATERIAL EMPLtCpti9ffNEfRODhAMODNr
Non-Water Supply Well: to ft Oured
❑Monitoring ❑Recovery ft ` ft:
lnjecdon We1f_
R ft
❑Aquifer Recharge ❑GmundwaterRerriediation I9t'SAIYD/GItAVEI;:ptICYC i `°timtile
❑Aquifer Storage and Recoven, ❑Salinity Barrier FROM TO 1NAI1T3tIAL F1ISPIACEMFNI ME18Dn
❑Aquifer Test ❑SrormwaterDrainage It ft
❑Experimental Technology ❑Subsidence Control ft ft
McWhetmal(Closed Loop) ❑Tracer 0` Li1;iC'1;OG:stfiteb:�drlieiffiiite$neisitc
❑Geothermal(Heati n g/Co oling Retum ❑Other FROM TO DESQrIPTJON eutor bards so;urxlr
under Remarks /tl'l"rft
al�
4.Date Wells)Completed- 2-2 24well ID# �0 2-l"It 02`6f; rc a cl G
Sa.Wyell Location: R 10 ft
t 1 o tL Iry D ftX.
f ,
FaciliW iwncrNatri ft ft
FacilityWN(ifappti-W)
1 , _7 y��. S� c�, �i o 2022
Pltyst Address,City,and Zip IL ft
V`s
County Farces menotiicatioo'No.(PIN)
5b.Latitude and Longitude in degreedutiuutestsecoudsor decimal ilegreet.
(tr�well field,one Iat/long is satficiwt) 22.Certific Lion:
6.'Ls(are)the well(s): (anent. or ❑Temporary a'gnattncort etu5ed Well Contrator Date
BY stkningAis form,I hereby eerj&that the wells)was(.were)constructed in accordance
7-Is this•a repair to an existing.,well: ❑Xes or le�o! with.I5A-NC71C 02C.0100 or 15ANQ4C 02C-e IYdI t:ortslructloit Standards wag thitta
Ifthis is a repair,fill out.h,town wet/construction information aid mplatn the ttatttrc of-the �P1 V1*Js'fordharbeert pmvlded ta:the IrrJ/owner.
rrpairrtttderS'21 remarks section oronthabackof 0itform. 23.Site d$agitIm or additibudwell details:
r You MW us-6 the back of this page to provide additional well,site details or well
8,Number of-wells constructed: ! Whstruction details. You may aiso.attaeh additional pages:ifnbcessary.
For multiple injection or non-,vatersupply weps ONL with the same eonsbacffott,you can s+,bmitoneform. SMITLALIN51'UCTIONS
9.Tot21'we11 depth below land surface: J (fL) 24a.For All wells Submit this form"within 30 days of completion of well
Formaltiple wefts 14valldepeaifdrfferent(amnple-3@200'and201001) consductidnt0th'Cfoliowiag:
10.Static water level below top of casing. Zt��Ijxater level is about casing;use (g) Division of W9terQuality,Informadou Processing Unit,
"+" 1617 Mail Service.Center
6 ,Raleigh,NC 27699-1617
1L Borehole diameter. fin.) 24b.For Injection•Wells: In addition to sending the form to the address in 24a
V11above,also subnrit d copy of this foml'`within,30 days of completion of well
12.Well construction method: t`o 9 y canshutdion to the following-
(Lc-at)W' ,rotary,cable,diced push,etc-)
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FOR WATER SUPPLY WELLS ONLY: Divisioti•of Water Quality,Uudergroaud Injection Control Program,
1636'MWI Service Center,Raleigh,NC 27699-1636
I3a.Yield(gpm) Method oftest: BIOVM20 minutes 24e F01r Water.SDnnly&Iniectift Wells•:In addition to sending the form to
13b.Disinfection type:
HTH r 2 0'� 8te address(es)above,also submit one i:opy of this foim within 30 days of
Amount: completion of well construction to the Witty health department of the county
where eonstrutaed. If
Form GW 1 North Carolhm Department ofEovirooment and Natural Resom=—Division of Water 1, f
� tY j Revised Jai].2013
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