GW1-2022-10544_Well Construction - GW1_20221118

WELL CONSTRUCTION RECORD � �v
For Internal Use ONLY:
This form can be used for single or multiple wells
1.W.Il Co actor IRrma
tion:/ (�\I
Atr 14.WATERZONES,
FROM I TO DESCRIPTION
Well Contractor Name Deal v ft ` ft 9
0 o
�Ca1 ft J fk
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased the QR L Rif 'lidahle
FROM TO DMAETI THICKNESS MATERLSL
Barnette Well Drilling, Ina.' 0 ft SZ ft- 1 ("/L1 in- s g-Zf pL)(
Company Name 16-INNER CASING ORTUBING: eothehnaldosed-loo
+ FROM TO DIAMETER THICKNESS MATERIAL
2-Well Construction Permit�: ft ft in.
List all applicable well construction permits(1.e.County,Store,Variance,etc..)
ft ft in.
3.Well Use(check well use): 17.S6REEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic• ft. % in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. m in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) JIS_GROUT.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation C
ft Z� fc Rand/nt Poured
Non-Water Supply Well:
ft &
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19-SAND)GRAVEL PACK rf a iieabic
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATFnrAr. EMPLACE11tEVThtETHOD
ft fk
❑Aquifer Test ❑Stormwater-Drainage ft it
❑Experimental Technology ❑Subsidence Control
10.DRILLING LOG at_tnch additioiial Aeets ifneeessa
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPr10N(color hartiness soillruck e,-,•ain size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under Remarks) ft- 2 fr.
lai
It
4.Date Wel(s)Completed: "T-22, well ID# ft t 6 ft 5 v4C
qv
5a_Well location: � ft ,V ft. r�
✓Yal,+� �'LV�til� ��Z�2.r�> iU ft ft `.�'V •`�,
Facility/(�O�w)nerName. f FacccilityrIDft(ifapplicable) ft -�
0l� I�ZG� ice+ ! ft ft. 2022
Physical Address,City,and Zip 21.REMARK$
ji / Jim,
lV/ Uf{f�
CCl7wC.�•'I �� rj gr Ir%
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degreeslminutes/seconds or decimal degrees: 22.Cer' eatio
(ifwell field,one lat/long is srufficieat)
N 7��• f S/?1 W f ` z-
// Da
6.Is(are)the well(s): lidPermanent or ❑Temporary ignatrue o Ceed Well Contractor By signing this form,I hereby certi)5,&at the well(s)was(were)constructed in accordance
with 15A NCAC 02C.OI00 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or C3No copy ofthis record has been provided to the well owner.
If this is a repair,fill out Anoxm well construction information and explain the nature of the
repair under421 remarks section or on the back of thisform. 23.Site diagram or additional well details:
qq You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: J+ construction details. You may also attach additional pages if necessary_
For multiple injection ornan-tivatersupplywells ONLYwith die same construction,you can
submit oneform. 1� SUBMITTAL INSTUCTIONS
9-Total well depth below land surface: lJ V (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 2@100') construction t0 the following:
10.Static water level below top of casing: (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+' 1617 Mali Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. y (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
�j,,�(/� above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: A-1/ �Q'l`' I construction to the following.
(i.e.auger,rotary,cable,direct push,etc.) '
Division 0f'9V2ter Quality,Underground Trajection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
T a? Method of test: Blown 20 minutes 24c.For Water Supply&iniection Wells: Tn addition to sending the form to
13a.Yield(gpm) ' the address(es)above, also submit one copy of this form within 30 days of
13b.Disinfection type HTH Amount: (=' U�n&e-5 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Dcparhnout of Environment and Natural Resources—Division of Water Quality Revised Jan.2013