GW1-2022-10482_Well Construction - GW1_20221118

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This farm can be used for single or multiple wells
1.Well Contractor Information:
^ a: 14..WATER ZONES,
(�nJ(.2S!� �srl (�(1 FROM ' TO DESCRIPTION
Well Contractor Name /32ft. I �'/'q gft. 2,.S A-
33 7 , 2 ft .27'5;"L 3 1•
NC Well Contractor Certification Number 15.OUTER CASING(for.mulii-casedwells OR)I fIICKIVESSNER ff 'livable
_ MATERL9L
Barnette Well Drilling, Ina: FROM TO' ft ft. DIAMETER T in.
Company Name tG.INNER CASING OR BINGIgeotheknial closed-loop)
—7 FROM TO DIAMETER TRICKINESS MATERIAL
2-Well Construction Permit#: 9 ft. fL in.
List all applicable well construction permits f e.County,State,Variance,etr-)
ft ft in-
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SUM TRICKINESS MATERIAL
❑Agricultural ❑MunicipaWublic• ft. ft h•
❑Geothermal(I3eating(Cooling Supply) ❑Residential Water Supply(single) ft• ft. in
OIndustrial/Commercial ❑Residential Water Supply(shared) 18_GROUT.
FROAf TO MATERIAL. EMPLAC&11EN1'METHOD&AMOUNT
❑Irri ation ft ft Sand/ Poured
Non-Water Supply Well: ement
❑Monitoring ❑Recovery O it Z d&
Injection Well: & ft
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PAC IC ifa livable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft.
El Aquifer Test ❑StorrnwaterDrainage & ft
❑Experimental Technology ❑Subsidence Control
2D.DRTLLIIVG LOG attach ad'ditioital sheets ifnecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCREMON(color,hardness,soil/rock e,. fnsze,etc
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) C) fr ft. uC 14_A t*
3 ft ft.
4.Date Well(s)Completed: ID#
IL 'tits ft ®L
5,aa.Well Location:
Facility/OwnerName Facility M#(ifapplicable) l q
,p/y 1 y� !A�-�,[�n M ],., �yy� Q ft ft '�.�.�• o.,• E4-v:
.3?e,5' �T �ro RI• / a'/ /r C/� ft ft
Physical Address,City,and Zip NOV-
21.REMARKS
�G�J t"J!C� f��C �£:,lC"1 try'": :�C •x Un 1
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification'
(ifwell field,one latllong is sufficient) f
Signature ofCettified Well Contractor Date
6.Is(are)the well(s): Dillefmanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C_0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or dM" copy ofthis record has been provided to die well owner.
If this is a repair_fill out known well construction information and explain the nature of the
repair under?:21 remarks section or on thebackof thisform. 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 of wells constructed: L 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. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface- ? (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2Cu 100') construction to the following:
10.Static water level below top of casing: IS' -(ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 24b.For Iniection 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: 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
13a.Yield(gpm) J Method of test: Blown 20 minutes 24e.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount completion of well construction to the county health department of the county
where constructed.
Foray GAT-1 North Carolina Department ofEuvironment and Natural Resources—Division of Water Quality Revised Jan.2013