GW1-2022-09297_Well Construction - GW1_20221006

;ELL C®NS RECO�
i TWj's' LC
h can 6e used for single or multiple wells For Inwual Use ONLY:
I-Well Contractor InformatioD:
t^ I�ti t n P"� Y4.YVATER ZONES
Well Contractarr�Name FROM TO DESCittPYION
I^ 1 -1 0ft lei? &
NC Well ContmctorCatificaticn Number ft ft
F R.•OYITLR.CASING formolti cyted'peUs O&.IJI!iER'ifa licgpte
BaMette Well Drilling, lne. Ftzonf TO DMMErER. rra
(�
ft L(V ft / ' MATFIUAL
Compaq Name �
s Y'S':INNS:Gi�SI1V6 it TUBING 'eti
2.Well Construction Permit l,�(� 31 �l U � xRont To fGtrrooal.e[odedd-• � ..
List all applicable xrll construction ermrtr DIAMETER 77rrC[QVESg MATERIhL
P (t.e.Comfy.State frarrance,eta) ft R is
3.Well Use(check well use): ft ft
in-
Water Supply Well: 1T::SG1Z);Ep(
OAgricaltural. trRAM TO D R SLO
IAMETET$IZE
OMunicipaUPabfic• ft R T�C�Fss MATeRUL
DGeothermal ia'
( ng/Cooling Supply) r esidential Water Suly(single)
QIndtrsfrial/Cotumcmmercial pp ft
OResidential Water Supply(shared)
OIrri scion tROM To
Non-Water Supply Well: ft ft §and/ pi''tCOMMML"MOD'&AMOUNT
C.eemen¢ our
jaitl oring ORecovery ! ' ft
IDjection WejL
OAquifw Recharge ft
OGrouadwater)tertiediation Yg:'S911ItY/r:1[2etiwh:.Ait `°til fife
OAqul&Storage and Rccovety FROM To
OSalinity Barrier MATFateL
OAquifer Test fit R EMrtwcentENTMetgOD:
OStormwatcrISrainage
Ofixperimental Technology OSubsidence Control ft fG
OGeothetmal(Closed Loop) OTracer 2UrY! L4N�'f OG;aitiiifi:13Crt°thermal nVC001ing Retum OM TO Ddt7`iSuciif-s
DOther( ] l explain under ) ieeeiosf:iefru hrxa�adas a
soiVrock, '
ft 7 ft
4.Date Will(s)Completed: �-3_ U-`)� well E* ft is- ft
I iJN^Sa Well Location: ft: 2-017 ft. 0;/ ,
ft ft
raahtylOwncrNamc R
Fadlity IDk(ifdppliable)
ft
physical Address Cky,and Zip . 't `_ k..:.3 l'?'._ !.•..
ft fk
1,l`!��{z L zr,3itElKrii<iic..: n
County //D�.r deattfi d Z�
1�rcelloatiol..(PIN)
Sb.Latitude and Longitude in d eWmitt El`�'`" • :^ ^u
(ifwep field,one lat/loagrs sdllieirnt) ds.cr dermal iteg[etS:
_fib 3X'�iV 3 N
6'Ls(Arc)thewell(s): OPermanent. or W
OTemporaty. Pure°ftCemeed Well'Gdntractar bate
By 4'ningAls form,l hereby certify char!he•wells)war 6—)ansrrncied in accordance
7.Is this•a repair to an existing,well: OXes or pNo WtAISAAVAC 02C.0100 or 15ANC4C 02C.0200 Well Cvnstrrl6e011 Mondatdrmtd fhala
Ijthis it a trpalr,�rd om known wel/aonstruetion itfotmaGoa card pairander S`2I rvwrkr section.or on rho.bock offor fomr. �����r?��hos beehpmvlded to the well owner.
re erplilin AL a?nrrcojtbr
23.Site'diagftm or addifibnalwell details:
&Number of wells constructed: You tday'use tEie back of this pao6 to Provide additional well.site details or well
For'"UNPre injection or non-water szpply wells ONLYwtth the setae wtcrbucGan,you can i;onshtrction details. You may alsii.sttach additional
submitotreform. pages,ifneces3ati,.
SUSIMMLINSTUCTIONS
9.Totai'wetl depth below land surface: 2, O J
.For mrdtipkwells&v all depdarjdocreri[(ezmuple-3Q200'and7wm ((f:) 24a. For A11 WrJL� Submit this form within 30 days a1s of completion of well
10.Static water level below top of casing: 2-s
Y"Ierkvelisabovecasing use^+^ (ft) Division of WaterQuAly,InformationProcessingUnit,
11.Borehole diameter
j(/ 1617 Mail Service-Center,Raleigb,NC 276994617
fn') 246.For IDiection Wells:
�1 in addition to sending the form to the address in 24a
12.Well construction method:_ JTi J tW(q above also Submit a copy of this forth'within.30 days of completion of well
auger,rotary.cable,direct push,etc.) eanstr'utdion to the following
FOR WATER SUPPLY WELLS ONLY: Divisiou.of Water Quality,Underground Injection Control Program,
1636 DWI Service Center;Raleigb,NC 27699-1636
13a.Yield(gpm) Method oftest: BI°wn20 minute 24t F0k.W kter.Snonly&Iniectiolr Welly In addition to sending the.form to
l'
13b.Disinfection type- TH drt'addr-s(es)81)Wt,also submit one copy of this foim within 30 days of
Amount_ 1.12 CUD Compleonstrif wd d.l construction to the cloutdy health deportment of the county
where Form GW-I
North Carolina Department of E-imnmem and Natural Resources—Division ofwarer Qimli
C
h! Revised Jan.2013