GW1-2022-09391_Well Construction - GW1_20221007

I
WELL CONSTRUCTION RECORID �
i This farm can be mcd for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information:
n d i rz 14.WATER ZONES
Well Contractor Name / BROM Tp " I
l _ z s� DESCE�TION
-
76� n Wft t
�io
NC Well Contrac(orCurifieation Number '•2s fc "a 2
I5 OUTER•(;A IG fortimlacasedaie1is OR•LINER'rfa lialole• ..
Barnette Well Drilling, Inc. FR°M TO DL,MErErt
T��O'rF.SS MA
ft 6 Z ft LI+RIAL
•Company Name �
Q �� Ys>Irli�iru:cAsnvc-oliTOBING mi6 dJ`
2.Well Construction Permit#:e �J FROM TO
List all applicable ueli construction prmits(r.e.Cmmry,State,Variance,eta) ft R DLMtElEg Ttr[C[pVESg MATERIAL
in
3.Will Use(check well use): ft ft in.
Water Supply Well: I7_'SCRI;EN."
OAgncultural PROM TO DIAMETER SLOTSIZE
❑MunicipaUPublic• ft ft in. TglcrrnFss :ifATER1AL
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
ft ft in
❑industrial/Commercial ❑Residential Water Su I (shared)
❑Irri atlon FROM TO
Non-Water Supply Well: ft ft ou TMEMOD'&AMOUNr
❑Monitoring ORet overy U ft
Injection WeM ft t e
❑Aquifer Recharge
❑ ft R
GroundwaterRetriediation ?.19 SA1�1DlGRxtV121;.t?ACXK if'...Ufa
❑Aquifer Storage and RecoveryP❑Salinity Barrier ROM TO L
MATERIA -: ._..- . .... .
❑Aquifer Test ft EMPRACFMFNr.UfETHOn
OStortnwater Drainage
OEXPerimental Technology ❑Subsidence Control 2 ft
❑Geothermal(Closed Loop) ❑Tracer :;2U tiRYI�Li140! UG"aitaeti;5dtli6ouiita$eeEs:itntcessg
17Geothennal(Heating/Co01in Relum FROM TO DFSQtIt14olr n soilhoak, •'.•� .-.
) OOOrer(explaintrader#21Remarks d ft 2 ft Ue/L 0N co =+ ta
D hW_6ard
e
4.Date Well(s)Completed well IA# Z ft /Z, ft
Sa Well Locative: 12 11r 3� (p'
�lJi/Oi A/yi Et ft
Factuty/OwncrNamc ftLf ft
Facility Mg(ifdppligble)
LP
Physical Addccss,City,and Zip ft R
caltuty
Parcel tdentificatioaNn.
(5b.Latitude and Longitude in fdegrees/minuteslsecondrorctecimal itegree3: 0i 'U G
':Ewell field,one laNtoag is saEieieot)
3/ _ _ 22.Ceriificatioa:
x S w ��� ^•�
6:'Is(arc)thew.ell(S): anent. or 'ii.`_QTCcW ie4 Well'Coa tAor "U �
OTetaporaty Date
gy mg»tng ibis farm,f hereby certify'hot the wells)was(were)constructed in•accordance
7.Is this.a repair toanexisting,well: OYes or 1]1!v with,lSA•NC4CO2C.0100or15ANCACO2C.0200'feel/Cottslir/ction&andandr mid that a
If this is a repair,fill ow btowa well comtruction iaforatatlon w+d up/nin die nthntrcofihr aopyofthfs!eaordhasbeM provided lo'the[yell owner.
Mmirvader 521 remarks section or on'hebaekoff r form.
23.Sit6'tfisgf9m or additiorialwell details:
&,Number ofwells.constructed: B You may use Cite back of this pane to provide additior l well site details or well
For multiple injection or non-watersupplpweUsONLYwtrhrhesmttecotrsritraffon,ymrcan bdh�cdondetails. You mayalso.atrachadditional Submitoneform, pagcs:ifriecestarl•,
SUOMMALINSTUCTIONS
9.Total"well depth below land sorface: �—��
Iormrdtplew car Lsrolidepriuijdi�eretrt fermnp1e-3Q200 aad7(rt)- (f-) 24a. For All Wills: Submit this fora within 30 d
r cbdn t6thefal(owing. ass of completion of well
10.Static water level below top of casing: Z S
Ifwaterlevel is above casing,use"+' (ft) Division of WaterQuality,Information Processing Unit,
1.1.Borehole diameter_ 1617 Mail Service Center,Raleigh,N`C 27699-1617
fin`) 24b.For Inimdnn.Wells: In addition to sending the form to the address is 24a
12.Well construction method: above also sitbnut a copy of this form within 30 days of completion of well
(i.c.augc{rotary,eabk,diced push,etc.) enn$trjrWon to the following.
Division of Water Qnauty,Underground Injection Control
FOR WATER SUPPLY WELLS ONLY: Program,
,( 16M Iliad Serwoe Centeri Raleigh,NC 2769946M
I3a Yield(gpm) U Method oftest Blown20 minute 24z IL O'er. &Iniecfiolt Wells' In addition to sending the form to
��'� Z ® tira adds ss(es)above,also submit one'copY of this fofm within 30 days of
13L Disinfcction type: Amount: completion of well construction to-the ty health department of the county
where constructed.
Form Gw_l
North Carolina Departmear ofFavitonment cad Natural Rescurar—Div=ion of Water Qoality ctiritt
Revised Jan.2013