GW1-2022-10545_Well Construction - GW1_20221118

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
e ` 14.WATER ZONES.
z, t�21.��( FROM TO DESCRIPTION
.
Well Contractor Name �t a ft y A� it
3 fL r ft
NC Well Contractor Certification Number M OTHER CASING for malti rased wells bR LINER if ']icable
_ FROM TO DIAMETER THICKNESS MATERL�7,
Barnette Well Drilling, Inc.' o f. � in. 'r 63vL
Company Name 16 INNER CASING ORTQBING. eofhekmal closed-loo
r FROM TO DrAMETER THICKNESS MATERIAL
2-Well Construction Permit#: Z 3 ft. fk in•
List all applicable well construction permits(I.e.County,State,Pariance,etc)
ft fL in.
3.Well Use(check well use): I7$ N
Water Supply Well: FROM TO I DUMErER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public• ft
❑Geothermal(Fleating/Cooling Supply) �dential Water Supply(single) ft. ft. in.
Olndastrial/Commercial oResidential Water Supply(shared) IS_GROUT.
FROM TO MATERLSL EMPLACE UNTMETMOD&AMOUNT
❑Irn ation ft. ft, t Poured
Non-Water Supply Well: L
❑Monitoring ❑Recovery ft 2�r ft
Injection Well: R ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK tfa Ijcabic
r ❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT MEiKOD
fk fk
❑Aquifer Test ❑StormwaterDrainage fL
❑Experimental Technology ❑Subsidence Control
20,DRILLING LOG attach additional slicers ifuecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(-I-,hardness,piuroclitype,gain size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft- fk UL.
ft. fk yG -
4.Date Wells)Completed: 6^6. ZZWell ID#
5a.Well Location: d S-ft ®ft.
FacilitvbyA Name. B� u� Fatality IDff((ifapplicable) ft ft.
7""'
Physical Address,City,and Zip 2L REMARKS
G®L.suj p
County Parcel Identification No.91N)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: lnfbi mati30 F-Inc lc3�;ng
(ifwell field,one latllong is sufficient) 22.Certification:
Signature of Certified Well Contractor Date
6.Is(are)the wel](s): lmanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or UNv— copy afthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under1,21 remarks section or on theback 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: (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 to the following:
19.Static water level below top of casing: (ft:) Division of Water Quality,Information Processing Unit,
Ifwater level is above casing,use"+" 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: construction to the following.
(Le.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 2 76 99-1 636
Method of test Blown 20 minutesDD
24c.For Wafer Suiv&Iniection Wells: In 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 1 5 0 7— e completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Fnviroameat and Natural Resources-Division of W ater Quality Revised Ian.2013