GW1-2022-10478_Well Construction - GW1_20221118

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This firm can be used for single or multiple wells
1.Well Contractor Information:
� 14.WATER ZONES.
O Pik ct D.-- FROM To DESCRIPTION
Well Contractor Name I ft to
fL /-0 ?l'
3 3 714 _A_ y<B ft 3o ft 1,46 �- m L1Wr4 v-e ltF3
NC Well Contractor Certification Number 15.01lTER CASING(for male-cased wells)OR LINER if 'livable
FROM TO DIAMETER THICKNESS MATERLAL
Barnette Well Drilling, Inc.' ft 6 ft. Vi in. Sda.ap 1/6
Company Name 16.INNER CASING ORTUIIING. eoth,* closed-100
g� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit N: ft. ft in.
List all applicable well construction permits(i.e.County,State,Yariance,etc.)
ft ft an.
3.Well Use(check well use):. 17.SCREEN
Water Supply Well: FROM TO DUMEfER SLOTS= THICKNESS MATERIAL
❑Agricidtural ❑MunicipaVPublic. ft. ft
❑Geothermal(Heating/Cooling Supply) EMcslidential Water Supply(single) it. ft is
❑Industrial/Commercial ❑Residential Water Supply(shared) IS_GROUT.
FROM TO MATERIAL EMPLACEMEW MEMOD&AMOUNT
❑Irri ation ft ft Peu>
Non-Water Supply Well: e
❑Monitoring ❑Recovery Q ft 943 ft eA.r/ -r U_A t
Injection Well: & ft
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK rf livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To IA MATERL EMPI.ACEM1tENT nIETROD
ft ft
❑Aquifer Test ❑StormwaterDrainage ft it
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG atach additional slieets ifuecessa
❑Geothermal(Closed Loop) []Tracer FROM To DESCRIPTION(color,hardn=%soillrock type,-nin size,eta
❑Geothermal(Heating/CoolingReturn) ❑Other(explainunder#21Remarks) ft ft ,p 6L4 .OJU
4.Date Well(s)Completed: ��i�i�-]_2 Well ID# 4 '�" D F S ~(
®Sa,Well Location: -2-7— 30 f t oe& f J, le
ft ft
em/oc K 3 U ft ft t5 !� j
Facility/OwncrName i� FacilitylD#(ifapplicable) ft ft NOV
�LI�N / /ZI'ftl OAS �Z�� Ae_ees ft ft NOV 1
Physical Address,City,and Zip 21.REMARKS Unk
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification-
(ffwell field,one Iavlong is sufficient)
Signature ofCertified Well Contractor Date
6.Is(are)the weD(s): MPe'rmauent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or WN6-- copy ofthis record has been provided to the well owner.
Iflhis is a repair,fill out known well construction information and explain the nature of the
repair underf2l remarks section or on the back of rhisform. 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 ofwells constructed: ( construction details. You may also attach additional pages if necessary_
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit oneform. SU$MTI I'AL INSTUC IONS
9.Total well depth below land surface: 41f tE) (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dieren,(example-3@200'and 2@100') construction to the follovving:
10.Static water level below top of casing: Z .5 (ft) Division of Water Quality,Information Processing Unit,
If-water level is above casing,use"r" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: i'T{� ti�/a'I(� 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 Sunniv&iniection Wells: In addition to sending the form to*
13a Yield(gpm) �' Method of test: the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type HTH Amount: completion of well construction to the county health department of the county
where constructed.
Form GlXt-1 North Carolina Department of Environment and Natural Resources-Division of Water Quatity Revised Jan.2013