GW1-2022-10487_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:
29.,WATER ZONES,
FROM TO I DESCRIPTION,
Well Contractor Name Qg ft �U ft 2—
r ft ft ,gyp A i0 �-� d � /�
NC Well Contractor Certification Number 15 OUTER CASING for multi-e�sed wells ORLINER ff 'licablc
FROM TO DIAMETER THICKNESS MATERIAL
Barnette Well Drilling, Ina.' 6ft f' Gib in. -a R7 , I to �
Company Name 16.INNER CASING ORTUBING. eothe'rmal closed-lou
/
2.Well Constriction Permit#: t(J FROM TO DIAMETER ft. ft in. THICKNESS I MATERIAL
List all applicable well construction permits ii.e.Coun(,State,Variance,etc.) ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
fr. ft ID-
❑A�icultural ❑Mu�nici�al/Public
❑Geothermal(fleating/Cooling Supply) L> esidential Water Supply(single) ft. ft, in
Olndustrial/Commercial OResidential Water Supply(shared) IS.GROUT.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑bTi ation ft ft dlnt
Non-Water Supply Well: 2
❑Monitoring ❑Recovery ft 3® ft
Injection Well:
❑Aquifer Recharge ❑GroundwaterIZemediation 19.SANDIGRAVEL PAC K rfa livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft ft METHOD
TO MATERIAL EMPLACEMENT MOD
❑Aquifer Test OStormwater Drainage ft ft
❑Experimental.Technology OSubsidence Control
Closed Loop) ❑Tracer 2D.DRILLING LOG attach additioiraj sheets ifnecessa
❑Geothermal
p) FROM TO DESCRIPTION(color,hardness,soillrock type,iniu sire,etc
❑Geothermal(Heating(CoolingReturn) ❑Other(explain under#21Remarks) 0
ft. fL a U—(L d/v
4.Date Well(s)Completed: 16-/2-X2 Well EM es 3fr 2 2
Z ft - ft N S
5a.Well Location: ���`tt 2 Go ft. L k
ft
Facili /OwcrName F rli IDF rfa livable
ty ty ( PP ) ft ft
ft NOV 1 8 2022
Physical Address,City,and Zip
,p 21.REMARKS
TI � f�/� 2 1 In;cy�,<� s_� ry-:�:� • J Uri{
County Parcel Identification No.(PIN) di' :1d1 uJL�
5b.Latitude and Longitude in degrees/urinates/seconds or decimal degrees: 22.Certification:
(if-well field,one ladlong is sufficient)
N r
- 9 5y P 3 w ��; jv -/ -a a.
Signature of Certified Well Contractor Date
6.Is(are)the well(s): l nent or ❑Temporary
By signing this form,I hereby cerl6 that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C_0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: OYes or Ito copy ofthis record has been provided to the well owner.
If this is a repair,.fill out known well construction information and esplai»the nature of the
repair under IVI 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 oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 60 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells-list all depths if different(example-3Q200'and 2 tt 100') construction to the following:
10.Static water level below top of casing: (ft) Division of Water Quality,Information Processing Unit,
Ifwarer level is above casing,use/T" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. C7 (in.) 24b.For Iniection Wells: in addition to sending the form to the address in 24a
p� above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: /7 90 construction to the following:
(i.e.anger,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) 7 Method of test Blown 20 minutes 24c.For Water Supply&Iniection Wells: In addition to sending the form to
AA the address(es) above, also submit one copy of this form within 30 days of
i3b.Disinfection type HTH Amount: (> a - completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Ian.2013