GW1-2022-10483_Well Construction - GW1_20221118

WELL CONSTRUCTION RECORD ForintetnalUseONLY:
This fomn can be used for single or multiple wells
1.Well Contractor Information:
F14.ROM TER ZONES
FROM
t � TO DESCRIPTION "
WellContracttoorNainc
ct )�V ft f®•�ft /�l'Oq��
3 74 -3-70 ft 3 ft
NC Well Contractor Certification Number 15.OMR CASING(for.mulli-cased wells)OR.LiNER if 'ticable)
_ FROM I TO DIAMETER THICKNESS MATERIAL
Barnette Well Drilling, Ina:' ® ft . Z �i _5&e 61L-
Company Name 16 INNER CASING OR BINGfecothelrmal closed-log
�7 FROM TO DIAMETER MATERIAL
2.Well Construction Permit#: /d ft. ft in.
Listall applicable well construction permits(i.e.County,State,Variance,etc.)
ft ft in.
3.Well Use(check well use): 17.SC-REEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
ft_ ft in.
❑Agricultural O�M��unicipaVPublic
❑Geothermal(Heating(Cooling Supply) n1Gidential Water Supply single ft_ ft.
(b � o PP Y) PP Y(• o )
Olndustrial/Commercial OResidential Water Supply(shared) 18..GROUT.
FROi4f TO MATERIAL EMPLACFMENT METHOD&AMOUNT
ObTi atiou ft ft. P> ed
Non Water Supply Well:
ft sa ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑GroundwaterRemediation 19.SANDIGRAVEL PAC K,f iicable
FROM TO MATRRI" EMPLACENIE�T1MiETROD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test OStormwaterDrainage ft ft
❑Experimental Technology OSubsidence Control
2D.DRILLING LOG attach additional sheets ifuecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soi0rock type,�!Mm size,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain underj#21 Remarks) ft L� ft. 6 L
4.Date WeIl(s)Completed: ](j•Il•22We111D# O I ler 0 ft zf'L fi t
a 2L eo ft usly $
5a.Well Location: //8 ft 6 ft fl"I G
}J K & ft
Facility/Owner-Name. Facility M(ifapplicable) i+ EmmE
ft ft i.�' �y...t'fi,Ara\1 ,
Physical Address,City,and Zip (/ 21.REMARKS NOV
County Parcel Iden"cation No.(PIN) {iTivi i very=t t"' '" 'J 'it
+a. lit
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lattlong is Sufficient)
® . 11-2 L 2.-Ct N Z- 2- W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): [WDef-manent 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 sm copy of this 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 under1,21 remarks section or on theback of thisform. 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. SOI3MITTAL INSTUCTIONS
9.Total well depth below land surface: ��C� (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 rQt 200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft) Division of Watcr Quality,Information Processing Unit,
Ifivater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection 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
13a.Yield(gpm) Method of test: Blown 20 minutes 24c.For Water Supply&Lniectiou 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 /6 ® '� completion of well construction to the county health department of the county
where constructed.
Form GAI-1 North Carolina Dcparimont of Environment and Natural Resources-Division of Water Quality Revised San.2013