GW1-2022-10485_Well Construction - GW1_20221118

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This farm can be used for single or multiple wells
1.Well Contractor Information:
A.WATER ZONES,
(,/✓J C 1 T FROM I TO DESCRD TION
Well ContractorNamc (� 4 ^oey�9 1,10 ft f(Z
l/y �V� L [L ft. ft
NC Well Contractor Certification Number 15.OIY=
'R N11or,mlDMew
FROM C lls ORS INER if 'livable)
.MATERLU
Barnette.Well Drilliny, o c6 D fk 61 ft i N in- SW--21 Puc
Company Name 16.1NNER CASING OR TUBING: eothekmal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: S l �� u IJ L4 -A y-a O Lz- ft in.
Listall applicable well construction permits(i.e.County,State,Variance,etc)
ft ft is
3.Well Use(checl:well use): 17.SCREEN
Water Supply Well: FROM TO I DIAMETER SLOT SIZE THICKNESS MATERIAL
ft ft. in.
❑Agricultural ❑Municipal/Pablic
❑Geothermal(Heating(Cooling Supply) Supply(single) ft ft in.
(E „/ pp y) dential Water Su 1
01ndustrial/Commercial residential Water Supply(shared) F8.GROUT.
FROAf TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation ft L 0 fr. andl Poured
Non-Water Supply Well: ement
ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Rem ediation 19.SANIDIGRAVEL PACK rf Ocabte
FROM TO MATERIAL EMPLACEMLNT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft fk
❑Aquifer Test ❑StormwaterDainage _ & ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG atNcL additioiral sheets ifuecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soillrocK type,grain size,etc
0
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under#21Remarks) ft. 7 ft. Sa
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4.Date Well(s)Completed: (��7-2Z Well ID# P''Z f r /D t!�
21a ft 30 ft 5 Al
5a.Well Location: ft b w J ft
M tut.
Facility/OwncrNam. Famlity IDA(ifapplicable) ft ft (("�� (,
ft
Physical At ddress,City,and Zip /` 21.REMARKS
!2c�,- 5o.,-\
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cer' a�n:
(ifwell field,one Iatdong is sufficient)
2 -7"d3 1 G mvl y-z-
� I (�(�� N l t(. �a W ! /V
Signre o ofCettified Well Contractor Da
6.Is(are)the well(s):"4ermanent or ❑Temporary By signing this form.I hereby certify that the well(sJ was(were)constructed in accordance
with ISA 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 Ehlo copy ofthis recordhas been provided to the well owner.
f this is a repair,fill out known well construction information and explain the nature of the
repair under?:21 remarks section or on the hack 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 one-form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface; �n �U (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Qa 200'and 2@100') construction to the following:
10.Static water level below top of easing: �� (ft) Division of Water Quality,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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I1.Borehole diameter: /L4 (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: >f-1 l Y o�,q 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
Blown 20 minutes 24e-For Water SuDDIy&Iniection Wells: In addition to sending the form to
13a.Yield(gpm} Method of test: the address(es) above, also submit one copy of this form within 30 days of
HTH completion of well construction to the county health department of the county
13b.Disinfection type: Amount U it Y1 C P 5 where constructed.
Form GW-i North Carolina Department ofEnvirontnent and Natural Resources-Divisian of Water Quality Revised Tan.2013