GW1-2022-07332_Well Construction - GW1_20220808

WELL CONSTRUCTION RECORD
This ftnm tan be used for single or multiple wells For internal Use ONLY:
1.Well Contractor Information:
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Wall Contractor Name FROM TMO DESCRaTfON
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NC Well Connactor Certification Numb- d.St / ft 2 cJ i
IS•011[f�ER.Ee1.SIlatG O(far timlh,eased:tvdCs ORILIIYER'if a Iirmbfe
Barnette Well Drr0@ing9 Inc® FROM fc Toll DL1MEr$t TIIICKNM MATP1tiAL
Company Name' 2�ft
1S1B111YlvItCi1SIIV�•Ok-T. CB1NG •eath rIosedci�O h
z.Well ConstrtrctioD Permiti1: ` )aft?111A�( FROM ro DIAMI'M TslcErrEss MATERIAL
List all applicab%Hell construction permits(t.e.Corrnly,state,Variance,etc.) ft is
3.Well Use(check well use): fw ft iR
Water Snpply;Wdl: 1Z:S4ltEEN:"
FR011f TO DIAMETER SLOTSIZE TH�C[QIFSS afATERUL
OGeoth anal ❑MUnicipal/public• ft in.
❑Geothermal(Heating/C-ling Supply) BlUt—mclential Water Supply(single) ft fa in
❑Industrial/Commercial ❑Residential Water Supply(shared)
0Ir71 atiOn FROM TO 6fA'FERUL,. F�t7pLACFJYtFMMETHOD&AMO[INT
Non-Water Supply Well: ft ft. out
❑Monitoring ��g'
❑Recovery ® ft
Injection wells
ft. fL
❑Aquifer Recharge OGroundwaterRetriediation 19'SAT /GRhV l,:pprCIC if:^ U 6Ie❑Aquifer Storage and Recover, OSalinity Barrier FROM To MATERIAL
FatrLAceMPxr METaoD
❑Aquifer Test ❑Stormwaterl)-iinge. ft fL
❑Experimemal Technology ❑Subsidence Control tt ft
❑GeQtllermal(ClosedLoop) ❑Tracer UbIO' `aitiieii:idiliuoniifalieelsffnecess9
❑Gwthumal(lteatlllg/CDOIIng Return) DOtha FROM TO DFSLRIMION enler.6a„L, soi0roek
1 Wlain under#21 Remarks ft ft a•rcr err
y -� fee
4.Date RTell(s)Completed ft�L-7'7&r lti2r Z R
Sa.Well Location• Z
e ,`'s he � iDi<►Ce I Ol t l�R
Facility/OwncrNaoie ft
Fadility Mg gf ippl"16)
it.
Physical Addreas,City,and Zips fL ft A.171 `1
ca�ty All (M'441rel G �"d Sfi/ s'0�' roc
Parcel ldeatificatioallo.(PIN)
Sb.Latitude and Longitude:in degrets/mirrptes/seeoadr or decimal degrEe3:Owell field,one tar/long is saffic;=0 22.Certification:
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6'Ls(are)thewall(sj: L7$e>"manent. or OTenaporary� Sasaannno>Cemfitxi Well Gontraetor Darr
By sk"UngAis farm,I hereby certify that 7.Is t the weft(s)was(were)constructed is accordance lris•a repair'to an existittgwell: ❑Yes or iDPPo' with lSH 1VCrlC 02C.OIOO nr ISA NCAC 02G.0200 Wet[Consriucrlon Standards add thcl a If this is a repair,fro our known wall construction information and copyofi/ur re4onf harbeenpmv/ded ta•�(le ledl owner.
Mwirunderf2l renrarksseclbnoronihe.backofikisform. _a&ntliananrr-ofrke
23.Site tLagitm or additibtial well details:
&Number oPweOs constructed: t Yo11 mflY tls6 the bacit of this page to provide additional well.site details or well
For.multiple injection or non-water au pp Iy wells bobstruct10n details. You frilly also-attach additional necessary.
submit Orel
ONLX wtrh the snare tonrtrucdon,you can pages.if
S1XIMMALINSTUCTIONS
9.Totafwell depth below land surface: 24a For All Walls: Submit this form within 30 days of completion of well
.For mulriple wells ltrtoll depnhs+ldi�ererir(ermnple_3@200-and2 00 — aY p
C� 0 constrtretionfothefo7towiug:
10.Static water level below top of casing:_- 7i (ft)
Ifxvter level is above casing,eve Division of Wat"uaHtY,Information Processing Unit,
1617 Mail Service.Center,Raleigh,NC 276994617
11.Borehole diameter-_�_(in.) 24b-For Ini 4%-on.Wells: in addition to sending the form to the address in.24a
17-Well construction method: above,also sublail'.6 copy of this form within 30 days of completion of well
(ca aaga.-twy.cable,direct push,et4) cansmttion to the following.
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Underground Injection Control Program,
1636 Mad Service Center;Raleigh,NC 17699-1636
I3a Yield(gpm) Method of test Bl°v1rn20 mina 24c FoY W4tei-.Sun'I &Infection Wells In addition to sending the form to
136.I)isinfectian gyp TH the addresses)above,also submit one'copy of this foim within 30 days of
e: (r� Amo�"01 completion of well construction to-the county health department of the county
where constructed.
Form OW-1 North Carolina D epartrneat afEnvimaarat and Natual Resaucees-Division of Ware Quality., Revised Jan.2013