GW1-2022-10504_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:
F WATER ZONES,
FROM TO DESCRIPTION!
Well Contractor Name 5-ft ft c/ U M. u—F i V
3 7 6`� ft M .
NC Well Contractor Certification Number 15.OUTERCASING for.mald-casedwells ORLMR if 'livable
_ FROM TO DIAMETER THICKNESS MATERL�1,
Barnette Well Drilling, Inc.' U ft $-,ft. 6 � in- 5&f2—z 1 vc
Company Name 1Cu INNER CASING ORTUBING: eotheimalclosed400
f FROM TO DIAMETER THICKNESS MATERIAL
2-Well Construction Permit& L� 2 cl 5 ft ft in-
List all applicable well construction permits ri.e.County,State,Variance,etc.)
ft & im
3.Well Use(check well use): 17.$CREEN . • .
Water Supply Well: FROM TO DIAMETER I SLOTSIZE THICKNESS I MATERTAL
❑Agriciiltural ❑MunicipaWublic- ft ft. in
❑Geothermal(cleating(Cooling Supply) �sidential Water Supply(single) R ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT.
FROM TO MATERIAL EMPLACFMENTMEMOD&AMOUNT
❑Irri ation it ft ( �f!•Itt Rsa!ed
Non-Water Supply Well:
❑Monitoring ❑Recovery 11 ft
Injection Well: & ft
❑Aquifer Recharge ❑GroundwaterRetnediation 19.SANDIGRAVELPACK ifa licab►e '
❑ FROM TO Aquifer Storage and Recovery ❑Salinity Barrier ft ft MATERIALI EMPLACEMEWMYMOD
❑Aquifer Test ❑StormwaterDrainage & ft
❑Experimental Technology ❑Subsidence Control
10.DRILUNO LOG attach ad'ditioinal sheets ifnecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,suilfrock e,gmin size,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) f1 ft I Q v C_ (9t'v
ft � �
4.Date Well(s)Completed: dV" Q7eJJVell ID# W- 2—&T7 �E 51 ft �� �,
5a.Well Location:
Facility/OwwnerName Facility ID9(ifapplicable) ft ft Y $ s gym^
9 1♦I
ft ft
Physical Address,City,and Zip
21-RE14ItiRICS
County Parcel IdemificationNo.(PIN) r,N'Q1B °R
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one Iat/long is Sufficient)
36_ 33f-I N 5`494ts W o -/q-Za.
Signatum ofCertified Well Contractor Date
6.Is(are)the well(s): L ant or ❑Temporary By signing this form,I hereby cert)�that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or &Nv-- copy ofthis record has been provided to the well owner"
Ifihis is a repair,fill out known well construction iglarmation and explain the nature of the
repair under 01 remarks section or on the back of this form. 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: / `7`® (ft:) 24a- For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dr feren((example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 7iJ (ft) Division of Water Quality,Information Processing Unit,
9water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
n above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: j�s� d C G) j� t�t/ construction to the following
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPP,L[Y^WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
U Method oftest• Blown 20 minutes 24c.For Wafer Supply&infection 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: Q Z completion of well construction to the county health department of the county
where constructed.
Form GWA North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013