GW1-2022-10514_Well Construction - GW1_20221118

RECEIVED
WELL CONSTRUCTION RECORD NOV 14 202
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: No
Dual O C 14.WATER ZONES,
FROM TO DESCRIPTION
Well Contractor Name ►ft O ft- Z
3 3 7 d 2?ofk ZeQ ft q- /Aq r
NC Well Contractor Certification Number 15.OUTER CASING for multi-c2sed weds bR x.INER if ']icable
FROM TO DIAMETER TRICIIN6S5 MATERLAL
Barnette Well Drilling, Ina: ft I yt Z ft 1 6*in. /- 0 1v
Company Name 16-INNER CARING ORTQBING. eotbetmaldosed-loo
Tinclai SS MATERIAL
2.Well Construction Permit#: � 9� 2— FROM ft. TO DIAMETER ft in.
List all applicable well construction permits(i.e.Coun(,State,Variance,eta)
• ft ft im-
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THiCI�`ESS MATERIAL
fr_❑Agricultural ❑Municipa]/P(iblic ft in-
❑Geothermal(fleating(Cooling Supply) esidential Water Supply(single)
ft. & in
❑IndustriallCommercial ❑Residential Water Supply(shared) I&GROUT.
FROM TO MATERIAL EMPLACEMENTMMOD&AMOUNT
❑Irri ation ft ft Gen+test Ptwl�
t
Non-Water Supply Well:
c
❑Monitoring ❑Recovery U ft. v �
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK rf iicable
❑Aquifer Storage and Recovery []Salinity Barrier FROM To MATERIAL EMPLACEMENT MEI'ROD
ft. fk
❑Aquifer Test ❑StormwaterDrainage ft ft
❑Experimental Technology ❑Subsidence Control
211.DRILLING LOG attach additioiral sheets ifmecessa
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION(color,hardness,soiUrock e,•min s ve,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft ft
,/ �j Y � �a �• � fr. ft e d t-
4.DateWell(s)Completed: •//`O eaVellMH ft 37z ft 0"ea oc<- O
Sa.Well Location: Me df9efz craft
FacilF/Ow=N�ame Facility IDI ifa licable ty /y� .y ty ( PP ) ft ft
-b� nJO�Q�� /•�®ta h�Iq L) •' ft ft. NOV
Physical Address,City,and Zip 21.REMARKS
County Parcel Identification No.(PIN) des U'
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficieat)
Signature o Certified Well Contractor Date
6.Is(are)the well(s): Bl'ermanent or ❑Temporary By signing this form.I hereby certify that the wells)was(were)constructed in accordance
with NSA NCAC 02C.0100 or 15A NCAC 02C-0200 f7ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or C&61 copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair undert`21 remarks section or an 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 suppTy wells ONLY with the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9-Total well depth below land surface: 3 C3 6 (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@a,100') construction to the following:
10.Static water level below top of casing• 2 S (ft) Division of Water Quality,Information Processing Unit,
Ifwater level is above casing,use"T" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehol'e diameter (in.) 24b.For Iniection Wells: In addition to sending the font 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
Blown 20 minutes 24c.For Water SuDuiv&iniectiou Wells: In addition to sending the form to
13a Yield(gpm) Method of test: p the address(es) above,also submit one copy of this form within 30 days of
13b.Disinfection type HTH Amount C �f7 Z- . completion of well construction to the county health department of the county
where constructed.
Form GIN-1 North Carolina Department of Environment and Naturei Resources—Division of Water Quality Revised Jan.2013