GW1-2022-10505_Well Construction - GW1_20221118

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well ontractorInformation:
I9.WATER ZONES,
FROM TO DESCRIPTION
WellContradorName ��V ^y„f t�t Q� )
NC Well Contractor Certification Number 15.OUTER CASING ffor multi wells OR f,D Rif 'lidable
_ FROM TO DIAMETER THICKNESS MATERIAL
Barnette Well Drilling, Inc.' a ft ® It ve
Company Name 16-INNER CASING ORTU DING. eotheimalclosed-lou
/� l® FROM TO DIAMETER THICKNESS MATERIAL
2.Well Constriction Permit#: � `'Y'"�J ft. TO
in.
Listall applicable well construction permits(i.e.County,State,Variance,etc.)
ft & in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MNURTAL
❑Agricultural ❑Municipal/Public- ft fk
❑Geothermal(kleating/Cooling Supply) 91<-dential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT.
FROM TO MATERIAL. EMPLACEMENT'METHOD&AMOUNT
❑Im ation It. fr
pwad
Non-Water Supply Well: t
ft ft. e
❑Monitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVELPACIC ifa licable
❑ FROM TO MATERIAL EMPLACEMEiNT METHOD
Aquifer Storage and Recovery ❑Salinity Barrier fk ft.
❑Aquifer Test ❑StormwaterDrainage ik
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets ifiiecessarA
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness omrock e,-,nin sire,etc)
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21Remarks) (' ft- �r ft- O
4.Date We1l(s)Completed:EU 2 We11ID9 3 S5"f'-� fk fD IL
f, 14.5"ft. v ce stJ
sa.Well Location: ds.i eti r h /33-IL 3 z ott. n
Facility/OwArName. Facility ID#(ifa/p�pliicable) fL ft y^ r5� �
�I+�d� ® t�G2A �..2.7✓t7 fk fkZ•. �.....0 A,.Z 9 �:� ��4I t
Physical Address,City,and Zip 21.REMARKS '"
County Parcel Identification No.(PIN) r. a P?l�,'u t_'
�ti
56.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if-well field,one lat/long is Sufficient)
Signature of Certified Well Contractor Date
6.Is(are)the well(s): fa anent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or IBA NCAC 02C.0200 Well Construction Standards and that a
7.IS this a repair to an existing well: ❑Yes or copy ofthis record has been provided to the well owner.
If this is a repair,fill out latown well construction information and explain the nature of the
repair under#21 remarks section or on the back of 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: 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 3 C_—o - (ft) 24a. For-All Wells: Submit this form within 30 days-of completion of well
For multiple wells list all depths if dierent(example-3 aQ200'and 2 tt 100') construction to the following:
10.Static water level below top of casiug• �� (ft) Division of Watcr Quality,Information Processing Unit,
Ifwater level is above casing,use"+"" 1617 Mail Service Center,Raleigh,NC 27699 1617
1t.Borehole diameter- O (in.) 24b.For Inicction Wells: In addition to sending the fort to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well cousti ction 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
® Blown 20 minutes Me.For Water SuDi ly&Injection 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
HTH /ti completion of well construction to the county health department of the county
13b.Disinfection type: Amount: where constructed.
Form G1:r-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013