GW1-2022-10503_Well Construction - GW1_20221118

WELL CONSTRUCTION RECORD r
Internal Use ONLY:
This form can be used for single armultiple wells
1.Well Contractor Information:
FROM
WATER ZONES,
f]\, FROM TO DESCRIPTION
WeIlContractorName 2--1' -ft y ft
L �'B QOft SGQa� a.
NC Well Contractor Certification Number
15.OUTER CASING(formuld-casedtvells)bRLMR if 'livable
_ FROM �TO D*�MR THICKNESS MA RIAL
Barnette Well Drilling, Ina: a ft ft S'a12,Z
CompanyName 16.INNER CASING QR INGIieotheirnal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft M 9n.
List all applicable well construction permits(i.e.Coun(,State,Yarlance,etc.)
• ft ft in.
Well Use(check welt use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
�-
❑Agricultural ❑MunicipaMblic ft ft
❑Geothermal(1-Ieating(CoolingSupply) ❑Residential Water Supply(single) ft ft in.
Olndustrial/Commercial ❑Residential Water Supply(shared) is_GROUT.
FROM TO MATERIAL EMPLACEM[ENTMETHOD&AMOUNT
❑Irri ation ft O ft Cement Poured
Non-Water Supply Well:
ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Rem ediation 19.SAND/GRAVEL PACK(if applicable)
TO
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft ft MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStotmwater Dminage it
❑Experimental Technology ❑Subsidence Control
A DRILLING LOG attach additiohal steers ifneeessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/mclt type,gmin size,etc
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under#21Remarks) fr ft -C S0e
r�
4.Date Well(s)Completed: fd�-Well W#7 04'5-f B"1f ft ft
ft rZ ft r Rock� ,}�
Sa,WellLocation: ( It ft
ep th,�/ 2�/�4 ft ft
Facility/Owner Name n Facility lD#(if applicable) ft ft. ' � ' "r 5 f '''ems
acci
1 I -:re �� 7 6 AJ ft ft NOV
Physical Address,City,and Zip •21.REMARKS
l�l� l�l1JJ! ae I n I i i:•� :ii�
County Parcel Identification No.(PIN) �lil>Q:ut
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification-
(ifwell field,one lat/long is Sufficient)
c
E.? ��
Signature of Certified Well Contractor Date
6.IS(are)the weil(s)::LSPermanent or ❑Temporary By signing this form,I hereby cert6 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: ❑Ycs or .Elf'ro copy of this record has been provided to the well owner.
If Als is a repair,fill out ktrown well construction information gird explain the nature of the
repair under.921 remarks section or on theback of thisform. 23.Site diagram or additional well details:
You may use the back of this pave to provide additional well site details or well
S.Number of wells constructed- 4 construction details. You may also attach additional pages if necessary.
For multiple injection or nat-ivarer supply wells ONLY with the same construction,you can
submit oneform. t SUBMITTAL LNSTUCTIONS
9.Total well depth below land surface: J a (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(Qa 200'and 2 a 100') construction to the following:
10.Static water level below top of casing: Z aJ (ft) Division of Water Quality,Information Processing Unit,
If-water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (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: 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
Method of test Blown 20 minutes 24c.For Wafer Supply&iniection Wells: In addition to sending the form to
13a.Yield(gpm) _ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount - 1 completion of well construction to the county health department of the county
where constructed.
Form G19-1 North Carolina Dcpartmont ofEnviroament and Natural Resources-Division of Water Quality Revised Jan.2013