GW1-2022-10484_Well Construction - GW1_20221118

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Ike
�� (y 14.WATER ZONES.
( .l l e 1 t FROM TO DESCRIPTION
Well Contactor Name
1 "C� P S v
NC Well Contractor Certification Number 15,OUTER CASING(for multi-eu wells.OR LINER if licable
FROM TO DIAMETER THICKNESS MATERIAL
Barnette Well Drilling, Inc.' Gft �ID ft I b y y in. v(
Company Name 6".INNER CASING OR-- BING. eothermalclosed-lob
jq FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: `l t & ft in.
List all applicable well construction permits(i.e.County,State,Variance,etc.)
• ft ft in
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM -To DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M/unicipal/Public- fL ft m-
❑Geothermal(Heating/Cooling Supply) MILidential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ig GROUT.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation ft D ft ft&e Poured
Non-Water Supply Well:
ft ft gdi14+..v i2
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Of applicable)
TO
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft ft MATERIAL EMPLACEMENTNIETROD
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additiotral sheets ifnecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hs%mess,soillroek cype,gnin Aze,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) � ft Z ft.
�" 3 yLt
4.Date Well(s)Completed: Z Well ID#T AX"/v�_l, ( /T_ / ft C� ft L
5a.Well Location: 70 ft ft
/ 70 ft &
Facility/04ncrNamc Facility ID#(ifapplicable)
fk ft
�I
n,�6
Physical Address,City,and Zip 21.REMARKS
County Parcel Identification No.(PIN) } 5r�3� ':�l •et1
tili3i;a�c>a�
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) c 22. ati
// of Certified Well Contractor Dal
6.is(are)the well(s): QPermanent or ❑Temporary By signing this form.I hereby certify that the wells)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 UNO copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair underf21 remarks section or on the hackof 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 die same consdaciion,you can
submit one farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 1�0 ( (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3Q200'and 2(✓a 100') construction to the following:
10.Static water level below top of casing: a� (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. A (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: �.1" Q�')a`fLl construction to the following.
(Le.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.Suonly&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. c Z 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 Jan.2013