GW1-2022-09308_Well Construction - GW1_20221006

f WELL fi CONSTRUCTION RE
used for single or multiple wells For latetnal Use ONLY:
1.Wel Contractor Information: .
ie
/ 14.WA k ZONES E
WaU Contractor Name FROMTO DESQtE MON
7� (S ft
fG NC �e I ConttactorCertification Number ft.
1 OUTt?R.(e15lNG for tact d-cased:-t3is OR•L1NEIt IieasUte
Barnette Well ®rill'ing9 pwc. I:ROM To DIAMOrm
��L 7 itICIQV�S$ MATERIAL
Co�iany Name rV -(ft 1 L in
I6�INIYCKCASI[VG•01tTOBING endlteitual.et 1' b �V�_
2-Well Construction Permitil: FROM To DIAM>+r1•a -'
List all applicable uell corutrualon n, 4 ft R T�C�i MATERIAL
permits flu! Cmoz Slat Parlance,etaJ in
3.Well Use(check well use): fL ft i„-
Water Supply Well: 7Z:SGR$EN."
OAgncultural. FROM TO DIAMEIEtt SL40Y.r
❑Municipal/Public- ft R is T� E� uATEtt1AL
❑Geothermal(H-tmg/Cooling SupptY) denlial Waters I sin
Supply( le g ) � Ft
01ndust ial/Commercial OR Supply Water Su Y(shared) '1Glt()LT''.',..
❑Irri scion FROM TO tFtATERiAL
Non-Water Supply Well: ft ft EKPLACOOMMLMOD'.&AMOUNT
OMonitoring tt our
Injection Wem ORecavery ft
OAquifer Recharge f ft
OGrauadivaterReniediation ?.Y9:'SA1vD/t;Ri[ '1,'p,Lta if' :tit tiie
OAquifdr Storage and Recovery FROM TO OSalinity Barrier MAT�uL uceiit
OAquifer Test OStnmtwater a++r ENT.nf>raoti ft. ft
OExperimental TechnologyDtrol
❑Subsidence Control 2
OGeotheimal(Closed Loop) OTtacer _ `: ObRIIsLfiNG°BOG'will;rb; daisdnd�hee�sifubcessa
OGeothc rmal(Hc ating(Coolin';Rehtm FROM TO D ON(eolO hardn o/
ESQtIPTir sitreek
) OOther{explain under#2I Remarks rQ it �. ft
Tv Sod
4_Date Well(s)Completed: 6—2 Z ,� Z tt Y 4 it
Well ItD# D4 d
Sa.Well Location: �'(( ft ft
(c
9, 1^0 ti F e t✓fwt R a.
FacluNlOwner add ft &
FaiilifyU�+(ifdpplipble) �, y•.t
Plrysical Address,City,and ZipfL
� ft
5
County
Pame1ideafificartoorNo.01N) nii
5b.Latitude and Longitude in d
�iAreU field one ladlolsee o°dsbr derimal itegreeS;
nS is snl&eieat) ntinums
cation:
N 7� ° / 9,9 7�
G.Ls fare)thewsil(s): QPermanent, or OTemporary $'g"tmeafCetdfietl Well'Connauor Dart
7_Is this•a repair to an exis6np.•well: es or ONO s U-NCA form.1 hereby cerrijy char the•well(,)was(were)constrveted- oocorAatrcr
with ISii NCi(C 02C.0100 or 13.t NGtC 020.0200 iFell C6nrfiuctlon SlaadaIn aced thaf e
If this is a repair fig out lwown well wnrtraclion it fotmalion surd �O O��!h���har•beM pt»vlded ia•the spell owner.mpairuader 1'21 remarla section ar on{he.baeko nfor form. mygain ilia naw coflhr
23.Site d'iagi�m or additfodal well details:
8�•Number of-wells constructed: YOU tni us6 the liaclt of this pave to provide additional well.site dtKails or well
For mulAplehVw1lonornon-watersupp[yweUsONLYwJrhlhesomecatsAttaYwn.youcan 00n��ondetaiLs• You may also.attaehadditiorWpages,ifnecessary-
submiloneform.
2 SUBM
9_Totai'well depth below land surface: J�0 IrrALINSTUCTIONS
ormyltrpleweUskaalldepd+s1fd$erentla.2mpit_T@200•and2WV-q) "]L)' da For A')VDdL= Submit this farm V�ffiil 30 days of Completion of well
10.Static water level below top of casing: S
Jfxarer level is above casing,use"+' (M) Division of Water Quality,Information Processing Unit,
j /� 1617 Mail Service.
11.Borehole diameter Center,Raleigb,NTC 27699-1617
k
< <n') 24b.For InPeenion.Vlxells: In dddition to sending the form to the address in 24a
12.Well construction method: ;
above,also submit a copy of this form within.30 days of completion of well
� / �. st r„1
(Le auae,meaty.cable,direct posh,ete,j) —mil eanshilwon to the following.
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center;Raleigh,NC 27699-16M
132.Yield(gpm) Method oftest Blown20 minute 24r_ 01rWAtek.SDnnly&Iniectioh wells In addition to sending the form to lira address es abov
13b.Disinfection type' HTH coin ( ) c,also Submit onekcopy of this foim within 30 days of
Amount: 1•12 Cup wherolcoonstru��l construction to-the c'ounty health department of the county
Donn GW-t
North Carolina Department ot'Eovirooro=t and Natural
Resources_Division
ofWater Quality Revised Tao.2013