GW1-2022-10480_Well Construction - GW1_20221118

WELL CONSTRUCTION RECORD For Internal Use ONLY-
This farm can be used for single or multiple wells
1.Well Contractor Information:
1
14..WATER ZONES,
FROM TO DESCRIPTION '
Well Contractor Name eel ��� ft tp ( t
3J 7F/:7N 46ft ,Zv---�ft ?� C A �. J U �'!� aSQ Al
NC Well Contractor Certification Number 15.OT117ER CASING(for.muld-casedw�ells)OR LMR if 'licablo
_ FROM TO M DIAETER THICKNESS MATERl9L
Barnette Well Drilling, Ina: ft z ft 5 Sa R 21I f1d C
Company Name 16 INNER CASING OR TUBINGfecothermal ciosed400
FROM TO DIAMETER THICKNESS MATEMLAL
2-Well Construction Permit#: �� ft. ft in-
List all applicable well construction permits(i.e.County,Store,Variance,etc.)
ft ft Lv.
3.Well Use(check well use): 17 SCREEN
Water Supply Well_ FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
[]Agricultural ❑M�unicipal/Public- ft. & in
❑Geothermal(lleating(Cooling Supply) QRgidential Water Supply(single) ft. ft is
[llndustriaYCommercial ❑Residential Water Supply(shared) IS-GROUT.
FROM TO MATERIAL. EMPLACEMEh"rMUMOD&AMOUNT
❑Irri ation ft ft �S'dff t Poured—
Non-Water Supply Well:
❑Monitoring ❑Recovery 6 ft 0 ft u
Injection Well: ft ft
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVELPACIC rfa iicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEtitENT METHODft ft
❑Aquifer Test ❑Stormwater Drainage ft
❑Experimental Technology ❑Subsidence Control
m DRILLIIV6 LOG attach addifioinal sheetsifnecesta
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPT10N(color,hardness,soillrock e,-,pin sire,etc
❑Geothermal(Heating/Cooling Return) 001her(explainunder021 Remarks)
4.Date Well(s)Completed: `I ZZ Well IIIoft-
5-tt 3s ft11
5a.Well location: bft-
Facility/Owner-Name Facility
1— /� Facility IDlk(ifapplicable) ft ft A`I���/ Q' )(+))
G IZR yjA� & L y ft ft N O V U Ll.'L
Physical
Address,City,
�and
TMZip 21.REMARKS
/10 3 {fl° i�ras."."i r :;3C.^✓:T: Fer'iSt
tUi
County Parcel Identification No.(PIN)
56.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22_Certification:
(if-well field,one]at/long is Sufficient)
��� Signature oFCertified Well Contractor Date
6.Is(are)the well(s): NBl'erDtanent or ❑Temporary By signing this form,I hereby cert6 that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NC-AC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Ycs or !3i la copy ofthis record has been provided to the well owner.
If this is a repair,_fill out known well construction information and esplain the nature of the
repair under i,21 remarks section or on the hack of this form. 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 noo-water supply wells ONLY with the same construction,you can
submit oneform. SUBMITTAL TiVSTUCI70NS
9.Total well depth below land surface: 30-e-�- (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdieren4(example-3@200'and 22@@100') construction to the following:
10.Static water level below top of casing: Z j (ft) Division of Water Quality,Information Processing Unit,
ffwater level is above casing,use"r" 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: "/Q Rk9 a construction to the fallowing.
(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
Blown 20 minutes 24c.For Water Supply&Iniection Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: y— the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount �J t�gg 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