GW1--06047_Well Construction - GW1_20230920

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WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells I For Internal Use ONLY:
I.Well Contractor Information: i1i i
Rex Meadows I4.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name ft [
2113-A t ft. I. I -
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if op Reable)
FRO Clearwater Well Drilling Inc. I M R. I g TO ID'�'" In.EIER I
'"'"`" MATERIAL
e/
Company Name 16,INNER CASING OR
�0�3 d C /3 A (Tothetmini closed-Woe)
SS
l/Jl FROM 70 DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: R. ft: in
List all applicable well construction permits(La Como.,State.Variance.etc)
ft. ft in.
3.Well Use(check well use): •
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural OMunicipat/Public in.
❑Geotherrtal(Heating/Cooling Supply) kesidential Water Supply(single) R. ft In.
❑lndustriaYCommeteial °Residential Water Supply(shared) I&GROUT I
QITCI$at10n - FROM TO MATERIAL EMPLACE"MENTMETHOD&AMOUNT
Non-Water Supply Well: I it ,q n ft � fl 2 )t. /4/,d
❑Monitoring °Recovery / R. R. J/'t; .1(r)
Ir/v J
Injection Wall. ft. R. i I
°Aquifer Recharge °GroundwaterRemediation 19 SAND/GRAVEL PACK(ifapplicable) I.
[Aquifer Storage and Recovery OSalinity Harrier FROM TO MATERIAL I EMPLACEMENT METHOD
R. ft. I
QAquifer Test OStormwater Drainage
°Experimental Technology ❑Subsidence Control It. it.
20.DRILLING LOG(attach additional sheets If necessary)OGeothennal(Closed Loop) OT,u� •
OGeothecma!(Hearin Conlin Return) °Other FROM IL To ft. DESCRIPTION(star;h.taar:.,swuaak e,Wahl Si,"�,1
(Heating/Cooling `'m) (explain under#21 Remarks) �� ft.
q � ( flt/®�")��-541 d1 r+
4.Date Well(s)Completed: — k.L e k prep ID# � 7 (.r�l /� I�p
Q7 R• 0V. ft ' 1 GC I
Sa. ell Location: g g 2 I I/+ t 9rarN
/e
R. ft
Facility/Owner/Name Facility IDit((iif applicable)
/ _ ,
,' 1.�y/104 �/s/- Dr, M/ea Cad d/,)6 ft. R. f ., �&�'�w ty�f) W ll
Phys al Address,City, �G 21.REMARKS �V
,.�1E40M . SE' 2 �UZ3
County Parcel identification No.(PIN) ,
Infi ;,ti crar;. 9 Una
Sb.Latitude and Longitude in d � v "" .2
ng degrees/minutes/seconds or decimal degrees: 711.Ce ffc oD: ` J y(if well field,one latRong is sufficient)
35� 9-3 °3j7D N 9' 7 5/z WJ"i -7t.. - -�q-a�
S tutrifcertificd Well Contractor i Date
6.Is(are)the weil(s)::(Permanent or °Temporary
By signing this form,1 hereby certf•that the ue/l(r)n I (were)constructed in accordance
with iSA NCAC 02C.0100 or ISA NCAC 02C.0200 ire 1 Constnrction Standards and that a
7.Is this a repair to an existing well: DYes or 110 copy of this record has been provided to thew!!owner.
if this is a repair•f111 out A77o1171 well construction information and explain the nature of the
repair under 021 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
You may use the back of this page to provide ad itional well site details or well
8.Number of wells constructed: construction details. You may also attach addition i pages if necessary.
For multiple Injection or non-walersupply wells ONLY with tiresome construction.you can
submit oneform. i I SUBMITTAL INSTUCTIONS
I9.Total well depth below land surface: 5 (ft•) 24a.For All Wells: Submit this form within 0 days of completion of well
For multiple wells list all depths MO-great(example-WOO'and 2@l00') construction to the following:
1
10.Static water level below top of casing: b0 (ft.) Division of Water Quality,litformati n Processing Unit,
1f water level is above casing,we"+"t 1617 Mail Service Center,Raleig NC 27699-1617
Q 1
II.Borehole diameter: /2 (in.) 24b.For Infection Wells: In addition to seadin the form to the address in 24a
Mt-CANabove, also submit a copy of this form Iwithin 0 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 In ection Control Program,
FOR WATER SUPPLY WELLS ONLY: ^ u 163E Mall Service Center,IRralefg NC 2 769 9-1 63 6
13a.Yield(gpm) ZO Method of test: ((Cfila 24c.For Water Supply&Infection Wells: In ad ition to sending the form to
the address(es)above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the c�nnty h th department of the county
where constructed.
• Form OW I
North Carolina Department of Environment and Natural Resources—Division of Water Quality 1 Revised Ian.2013