GW1-2022-10479_Well Construction - GW1_20221118

WEILLCONSTRUCTIONRECORD Fo[InternalUseONLY_
This form can be used for single or multiple wells
1.Well Contractor Information:
ti 1 14.WATER ZONES,
uL I I FROM I TO I DESCRIPTION.
Well Contractor Name �/ Z-/Ofk �®^' 9
C/ �
Y7& a—�'Qs y 0- ft. 3� fk O .
NC Well Contractor Certification Number M OUTER CASING(formalli-cased wells)OR I IIVER if 'livable
FROM TO DIAMETER TITICR RE T MATERLII,
Barnette Well Drilling, Inc. ® fk 6 ft- - Jldaz-a Ale-
Company Name 16_INNER CASING OR TUBING. mthetmal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL.
2.Well Construction Permit�: � �� ft & in.
List all applicable well construction permits rr.e.County,State,Variance,etc.) fk ft uw
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To DIAMETER SLOT SIZE THLCMVFSS MATERIAL
OAgricultural ❑Municipal/Public- ft. ft, im
❑Geothermal(IIeating(Cooling Supply) ❑.Residential Water Supply(single) & fk in.
❑Industrial/Commercial OResidential Water Supply(shared) 18.GROUT.
FROM TO EMPLACEMEh'TMETMOD&AMOUNT
❑RTi ation & ft aadG Poured
Non-Water Supply Well:
❑Monitoring ❑Recovery 6 A"r
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK rf iicable
❑Aquifer Storage and Recovery ❑ FROM TO Salinity Barrier ft & MATERIAL EMPLACEMENTMETROD
❑Aquifer Test OStormwater Drainage ft.
Technology ❑Subsidence Control
21D.DRILLING LOG attach additloiaal streets ifueem2
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTIONf-lax hardness,soillrock type,gwinsw,eta
❑Geothermal(Heating/Cooling Return) []Other(explain under621 Remarks) ft. ft.
ft. ft. "
4.Date Well(s)Completed-�Z 1Dff ft f- .god wyt Z3
5a.Well Location:
Facility/OwnerName. Facility ID$(if applicable) j
A�r. e)-�'� CG Fg ft. ft. P �lov,F
fk ft
Physical Address,City,and Zip
21_REMARKS 0 L022
County Parcel Identification No.(PIN) Ii -0 v
r.;fit(-,c,:
5b.Latitude and Longitude in degreeslminutes/seconds or decimal degrees-, 22.Certification-
(ifwell field,one lattlong is sufficient) L
Sigoaoue ofCertified Well Contractor Date
6.Is(are)the well(s): MPermanent or []Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 9?ti copy of this record has been provided to the wag owner.
1f this is a repair,fill out known well construction information and explain the nature of the
repair underi:21 remarks section or on the back of thisfonn. 23.Site diagram or additional well details:
D 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 ONLFwith the same consruction,you can
submit onefarm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 5leo (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: g~ (ft) Division of Water Quality,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending 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: construction to the following.
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
132.Yield(gpm) Method of test: Blown 20 minutes 24c.For water Supply&Iniection Wells: In addition to sending the form to
,+ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type HTH Amount ® ® completion of well constmction to the county health department of the county
where constructed.
Form GW-1 North Carolina Dcpartmont of Environment and Natural Resources—Division of Water Quality Revised Jan.2013