GW1-2022-09401_Well Construction - GW1_20221007

'6WELLn
CONSTRUCTION RECO
t This farm ca be ascd for single or multiple wells
For Infernal Use ONLY;
L Well ntractor Information:
/vt%l,f • L�b tA.wq'1'ERZUNES 1
Well Cont acb.Name FROM To DESCREMON
NC Well Contractorccrtifieation Number �'f t /jd f t (�3� 6�` r�a 1 5
`6 p�y '�f, .....1lTER.CAStPIG forl mlti.rued.�vi�s OR�LINER'ifa licitble• ..
Barnette W011 Drilling, Inc. FROM � TO DL�MECFR' rIIItT4VESS attrERrAI
-Coagaaay Name
U �' ft- 6 '� sdvz J
/� Ys:n�nci:c�tsinviy oR roslN� mie ;a1.. i a3
2.Well Construction Permit#: PRO M To Dt4ME[ER rglC[BVFS3 MATERIAL
List all applicable'Pet(construction permits f.e C-1y.State,lradanee,ere.) ft ft is
3.Well Use(gheck well use): & it iR
Water Supply Well: 1T:SG1t$gay:'
NIWM TO DIAMETER SLOTSPLE rHICKNM lfArERrAL
� '� a OMunicipal/Public• ft ft is
OGeothermal(14eating/Ctioling Supply) �ential Water Supply(single) fL ft is
[]Industrial/Commercial OResidential Water Supply(shared) 'Ya1fOUi .'. ..
Obri ation ! FAOM r0 t1tAFERLII ! EMPLACtrJHENTlrlLm0 &Ailioorrr
Non-Water Sup ply Well: ft ft and/ our
ment
11Monitoring ORecovery ft &
Injection WeIC
ft ft
OAquiferReeharge OGroundwater•Remediation Y9CSAIY /G1L4t I,:l',4CTCif °lit bte OAquifirStorageand Recovery ❑Salinity Barrier FROM To MATERIAL
FIHPLACEMFN7'.MMOD...
OAquifer Test'. OStomtwater ft ft
i Ihainage
OExpetimental Technology OSubsidence Control it R
OGeathermal(Closed Loop) OTracer `;211•,?11ItiGLIIiI9109'aHiicli:Vd4d6niif•a eets:itutce sa
OGeothermal(Lating(Cooling Return) ❑ {Other FROM ro DFSCtiIP7ION wlor bardn sdillnek .
explaiuunder#2LRemarlrs Fj ft � ft
I /
4.Date Well(s)!Completed _ � ell'1D# it �./ ft RtQ�
Sa WeU Localiun: 7-5— f
_fr9/17ALfy d�p9ld1 r�y� �`' bfA l�C.
Facility/Owner ame ft ft
Facility M(if dppIicablE) r'
;�� /R
Ph i A'ddress,City,and Zip ft ft Q
County
Parcel Tdcatifieatioallo.(PIN) _ �`�L°r,;
5b•Latitude andlongitudein degrees/nuttutes/seeondsor decimal,,egrets:
Owell field,one laf`/long is saScient) 22.Certification: r
6"Is•(arcythe well(s): �rnranent. or OTemporaiy S'�°ofCettrfied Well Caattattor Date
$y stgnfng Alas farm,1 hereby ceriffy that the•weU(s)was(were)constructed in accordance
Is tills-a repair to an exisiitig,weU: OYes or � *vfth 13A-NCAC 02C.0100 or I5A•NCAC 02C.0200 Wdl Cdnsf ddoh StandordsA26d thni•o
If this is a repair fff out known'Pelf comtracrion h formation gid..-erp(crn the nphrmofthr �tls recnrdharbeen pmvlded to the Vdl owner.
mmirander#21 rcr�rarla section or on{habaek of'this form.
23.Site( agitm or additional WeU details:
ll_Number of wells constructed: YOo Y tisE Sit liacit of this page to provide additional.well.site details or well
For muirpreinjectionornon-ivarersa iainstructiondetails. You niayalsd.attaeh additional pages:ifnecessary,
mibmironeform, peaty we0s ONLYwuh fhesame eohsducton,you can
SU�BMC[TAI,INSTUCI'IONS .
9.Total well depth below land surface: 1
1'armn(tlple We&finall de rhs f d'Brent (fly 24a. For All Wells: Submit this form within 30 trays of completion of well
P I (erarttple-3Qa 2000',ndd2@1001 t>�etido to the following:
10.Static water live)below top of casing: Z5 Ifwater level it above casing ( ) Division of Water use"+" ft Quality,Information Processing Unit,
6 161.7 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: Ca) 246 For Injectiou Welts: in addition to sending the form to the address in 24a
12.Well construction method: above also submit a dopy of this form within 30 days of completion of well
C4c-a�.-tary,cabic.dater paste,etc,) cmisb abdon to the following;
FOR WATER SUPPLY WELLS ONLY: Division-of9Vater Quality,(Jnderg round Injection Control Program,
106 Mail Service Center;Raleigh,NC 17699-16m
I3a Yield(yearn) Method oftest: Blown20 minute 24¢Fm-Wskter Sunnlir&Injection Wells In addition to sending the form to
136.Disinfection type
HTH 49 1z, the addresses)above,also submit one Icopy of this foim within 30 days of
Amount completion of well construction to the county health department of the county
where construeted.
Form OW-1 North Carolina Depadarent ofEnvimameut and Naawl Resources-Division of WaferQuality
Revised Jan.2013