GW1-2023-01096_Well Construction - GW1_20230126

WELL CONSTRUCTION CORD
rn;H rnrm USea raralog(c or multiple wells For internal Use ONLY.-
Well Contractor Information:
Rex Meadows
14.WATER 7.ON&3 � -
WelicnnttnciorName FROM TO DSSCiI1P7ION
2113-A
fl. ft. h
NL'1'VC11ConhnetarCert(RcntionNumber I&QV=RCASING tartrtntliea+miwelb ORLRV$R
Clearwater Well Drilling inc. FROM TO DIAMETER ' THiCKNggg MATERIAL
Coml+nny Name I ft. ft L {a•
l�,'7 _ IfUNIMCANNCORIM G dosedlno
z•Weli ConstrnctinR Permit#: tJ/ ���� t7tOM TO DiAMtLT6R THICKNESS MATEltlAL
I.isletllapp/lmblertellrgaygtrt7lon — It tR its pmni[c(Le.Caml/yt,Slgla,lrarigOrr,elnJ
3•Well Use(cheek well use): fl• fl- 1%
tHeatin
er Supply Wen: 17.SCREEN
ticnimml seOM To DtAMRiEa OTSM THiciQMF84 MATfuIAt
[3Mun(cfpaUPublio rr, fl. In.'
ustertttal(mca
mercg/CoolingSitpply) Aesiderafill Water Supply(single) ft.
ustdai/CominereiEl OResidential Water Sn 1 shnred) 18.GROUT
( lion Supply( FROM To MATERIAL EMPLACEMENT MMon&AMO�yT
Non-Water SuPP1y Well: iL R.
nitoring gReeovery n• tr.
tion Well:
uiferRecharge 41. fL
RGroundwater Remediation ]4. VEL PACK f -IlHble
iferStorageandRecovery Malinity Barrier rROM TO MATERIAL EMPLACEMENT METHOD
iferTe�t O. it.
QStotmwater Drainage
erimentalTechnology 13SubsidenceControl
therrnal(Closed Loop) IlTracer 21L DRILLI G LUG atlac6.ddlilaw a trl.irDeem„.
PROM TO DESCRiPTION mkt coiLmak eta
thetmal Heatin Coo(in {Return gather lainunderfl2l Rematis D• r►. '/
4.Date Well(s)Completed: V �r Z�r fl• 9.
Well IDN
Sa.Well Loeadon:3aq �,E' cRcn O. O..
Facility/owncrNamc ^"
1 6/ �Ae Facility rDN{`ifapplicnblc) � '--•S'✓-�� 6e ,.,.r
P al Address,Coy,mrd Zip n• B• JAN ZV
21. MAIMS�
Cmrnty
Parcel identification Lion No.(PM) =
Sb.Latitude and Longitude in degree0/minutWseconds or decimal degrees:
(if well field,one 1,t&ng is suflicienQ
!, CerB Lion:
� � ►
6.is(are)thoweil s• Signature ofCertified Well Contractor(). Permanent or OTemporary,
9.Is this N rc ai RJ'signiag rlrlc fnmz I hcTehr•Cerrr that the ur/1(sj,,¢s�,rr��,�pqr �fo atrnrrlrumc
p r to an existing wen: OVee or u bulb fSA NCAC OdC.010D or/SA NCAC D2C.0200'Pell4i»trfrircllnn Sraarlardc mrdhnr l a
/lrhic lc a ny,rrir,,frll mu fiamt�r tsxl/caaslrrrrJinn 1,�armq!lnrr an eDJ'J'oflhty record/ray horn prrmidrd in iJ,e nrNrinner:
rr:pnir uric,•$21 rrmOrli secgna nlroB the hack r flhisfor n. aln the aanrrrafihc
'23.Site diagram or additional well detalls:
li.Number of webs constructed; You may use the back of this page to provide additional well site details or well
Fru'malliple/jectiml Organ-rvalersrgply wells ONbI'wuh the same catcslrrrctlrrn.J�rr rm+ G0110racttan delaifs. You may also attach additional pages if necessary
srrlrn,il aarfarO,.
Total well depth below rand surface: Q O SUBMITTAL INSTUCTION3
Fnrnprl8plcnClls/Lriollrlrplltai/drreal(esnmpfc-3@209'mrd2@ 001 (ff) 24a• F'ar All Wells: Submit this fort within 30 days of completiart of well
construction to the following:
I O.Static water level below top of easing:
j1l+n/rrirvcllrahmvrrasln},aye"t"` (ft.) Division of Water Quality,Info Processing Unit,
11.Borehole diameter. 16t7 Will Service Center,Raleigh,NC276994617
CD') 24d For Iai�eetift Weliv; rn addition to sennding the form to dle addr in 2qn
12-Well construction method: rn-� above, also submit a copy of this form witltfn 30 days of completion of well
Huger,mtnry,cable direct push,etc•) ---- aonStnraion to the follnWiltg: I
FOR WA Division of Water Quality,Underground injection Control'Program,
7'RR Sl1PPI.V WELLS ONLV:
i636"I Service Center,Raleigh,NC 27699-Ib36
13a.Vield(gpm) f`
Method of test i LiL 24e.Rot Water Sunuty&iMecHnn We_ 1_r ^jn addition to sending file faint to
13h-Disinfection Iype, rho addres9(es) above,also submit one copy of this form within 30 days of
Amount: comple ion Of Wi fl construction to the coup'
whcrcconstnicted t3' with department of the county
rn„n cw_t l
Nndh[Mallon Depnement of F.nvimnmcnt and Nnarml Resnurccs •r)ivistnn of Water Quality
Revised.lan.201.;