GW1-2022-10486_Well Construction - GW1_20221118

I
WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be-used for single or multiple wells
1.W Contractor Information:
g
.7!y!l/ .D 24=WATER ZONES.
r FROM TO DESCRIPTION`
Well Contractor Name ft ft
3 9 '7 �-' "/-,;-
ft. ft
NC Well Contractor Certification Number 15.OUTER CASIPIG for.mal,i-used witus OR LINER if 'livable
FROM TO DIAMETER mucle Ss MATMAL
Barnette Well Drilling, Inc.' ® ft 6 z ft 6 /® in. -5 F--e-o U
Company Name 1C,INNER CASING OR T Izmtherinal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft
List all applicable well construction permits(i.e.County,Stare,Variance,etc..) ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well_ FROM To DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑�M� �unicipal/P
ablic- , ft. ft.
is
❑Geothermal(Heating/Cooling Supply) dkresidential Water Supply(single) ft. ft- in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1S_GROUT.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑H ation & ft .9andf
Non-Water Supply Well: oe
nwgnt
❑Monitoring ❑Recovery ft 70 ft � LL
Injection Well: % ft
❑Aquifer Recharge ❑GroundwaterRemediation 19.SANRIGRAVEL PAC 1C ifa livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENC METHOD
ft ft.
❑Aquifer Test ❑StormwaterDrainage ft it
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets ifliecess2ryj
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hudnrss,soit/rock type,grain tim'etc
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) Q ft ft J C r(j
4.Date Well(s)Completed:LO-1Z7-y2Ve11 W# �� ft /� K S c
5a.Well Location: ft ft
Facility/Owwner/Name. Facility IDS(ifapplicabblllee) ft ft
fff 5+tme- ft fk
Physic dress,City,and Zip 7
21.REMARKS (-
County Parcel Identification No.(PIN) }j+tll�,i[ir}iJ
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field pone lavlongis Sufficient) p �-
-7 01
3 L_ ®U®93 N 0 J W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): SPCrmartent or ❑Temporary
By signing this form,I hereby cerl�that the wells)was(were)constructed in accordance
with IBA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Ycs or laBhr-- copy ofihis record has been provided to the well owner.
If this is a repaii7 fill out h7ottm well construction information and explain the nature of the
repair under?21 remarks section or on the back of thlsform. 23.Site diagram or additional well details:
6 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 OI LY with the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 3 �4 (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'avid 2000') construction to the following:
10.Static water level below top of casing: (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: 6 (in.) 24b.For Iniecton 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( � �Ca �1�� �/ 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 Suuuly&injection Wells: In addition to sending the form to
0 the address(es) above,also submit one copy of this fern within 30 days of
13h.Disinfeeh on type HTH Amount _f completion of well construction to the county health department of the county
where constructed_
Form GW-I Nordi Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013