GW1-2022-10469_Well Construction - GW1_20221118

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mi ltiple wells
1.Well Contractor Information:
14,WATER ZONES.
® i0�(( '; . lot,L'I I FROM TO .DEkkirTION
Well Contractor Name IMP
ft 6Z ft R 1
3 2 ;;I G 19 3-74 ft 72- rk Q6 - �q-
NC Well Contractor Certification Number 15.OUTER CASING(for.multi-used wells)OR LINER if 'licable
_ FROM I TO DIAMETER THICKNESS MATERL�1.
Barnette Well Drilling, Ina:' O ft 3 ft (� 4-in. -'a,Q21I rP /-
CompanyName t6.INNER CASINGORTUBING: Bother etosed+loo
t� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: X irA``,,��'11J'R 2 2 0 8.d®�,� ft ft in.
List all applicable well construction permits i.e.County,State,Variance,etc.)
ft ft is
3.Well Use(cbeclr well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public• ft ft m.
❑Geothermal(Heating/Cooling Supply) CIIRZgidential Water Supply(single) ft. ft
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT.
FROM TO MATERIAL EMPLACEMNrMETHOD&AMOUNT
❑Irri ation ft ft $aed/nt ;Fe d
Non-Water Supply Well: �:effte
❑Monitoring ❑Recove v ft 2S ft Bi@
a ry
Injection Well: ft M
❑Aquifer Recharge ❑Groundwater Rem ediation 19.SANDIGRAVELPACK da ficabte
❑Aquifer Storage and Recovery ❑ ft Salinity Barrier FROM TO fG EMPLACEMENT NIETROD
❑Aquifer Test ❑StormwaterDrainage ft it
❑Experimental Technology ❑Subsidence Control
$D.DRILLIIVGLOG attnchadditiohalslieetsifnecessa
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION(color,hardness,soil/rock -,--nm sire,etc
❑Geothermal(Heating(Cooling Return) ❑Other(explain
tlunder#21 Remarks) 0 ft ft. ,Q kA-fLt®'0�'
4.Date Well(s)Completed: A®•ZD well ID#(' /i 1/��22 d$�-�� 2-2
ZZ
5a.Well Location: 5-ft 3 75-ft.
e N'N ft ft l
Facility/OwnerNam p (� Fam7ityIDf(ifapplicable) ft ft
2- 2.1 A /� 4 6- ft ft.
Physical Address,City,and Zip 21.REIIIARI{$ OVI7
p t.
9C�G f���ff�9'Ii'2 �G z y'�®77�/tY r^ _
County Parcel Identification No.(PIN) �f1,t,irte�>tiC7 +^C?�;e^^ Unit
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(ifwell field,one lat/long is sufficient)
36 .3115-00 I N 7 9- •S976 4 W E1�6 d t?,-zV
Signature of Certified Well Contractor Date
6.Is(are)the well(s): VWFmanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Iwo copy ofthis record has been provided to rise well owner.
If this is a repair,fill out known well construction information and esplain the nature of the
repair underi:21 remarks section or on the backofthisform. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary_
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For muldple wells list all depths if different(example-3 tQ200'and 2 rr 100') construction to the following:
19.Static water level below top of casing: (ft) Division of Water Quality,Informaiou Processing Unit,
guater level is above casing,use"+` 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: C7 (in.) 24b.For Inicction Wells: In addition to sending the form to the address in 24a
an above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: f"" 7�bn � construction to the following.
(i.e.auger,rotary,cable,direct push,etc.) r
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
C ®® Method of test: Blown 20 minutes 24c.For Water Supply&Infection Wells: In addition to sending the form to
13a Yield(gpm) the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount-���i •67, completion of well construction to the county health department of the county
where constructed_
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised San.2013