GW1--06255_Well Construction - GW1_20230925

I •
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Rex Meadows 14.WATER ZONES I ,
FROM TO -DESCRIPTION
Well Contractor Name ft. ft. I '
2113-A ft. it.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR[INER(if a Usable)
FROM TO DIAMETER . THICKNESS MATERIAL
Clearwater Well Drilling Inc. ft. R. in.
CompanyName 16.INNER CASING OR TUBING(geothermal ctosed400p)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. fL I in.
List all applicable well construction permits(i.e.County.State.Variance.etc)
R. ft. M.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SUE THICKNESS MATERIAL
❑Mtmicipal/Public n• H. in. I
❑Agricultural I
'Geothenmal(Heating/Cooling Supply) ❑Residential Water Supply(single) B' R' , 1O' I
/❑)ndustrial/Comercial ❑Residential Water Supply(shared) 18.GROUT 1'
m 1
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation (^,v:��_t r.-`1 ;.n ft. frt. I
Non-Water Supply Well:1.la.%.d L. V1 t-.•I
ft.
❑Monitoring Qvery B.
Injection Well: S E P I- 5'LUCJ rt. ft. 1I
❑Aquifer Recharge ❑Groun¢ivater Remediation 19 SAND/GRAVEL PACK(IfappUcable)
t fc� {;„. , U+rL: FROM TO MATERIAL EMPLACEMENT METHOD
f7Aquifer Storage and RiV e ` miry Batrier ft. IL
❑Aquifer Test ❑StonuwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control .20.DRILLING LOG(attach additional sheets If accessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardens,sell/rock type.praln she,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rt. 30D n•
ft. R. r V)+ r (SOS)a
4.Date Well(s)Co feted: Sell 1D# R. R. .
Sa.Wsli I.o don: m�'� �1� It. rt. i
KirT Job ft D.
Facility/Owner Na Facility Facility ID/1(if applicable)
1 1t1 P neC o`c& t d . ? v, c)v. .- ft. ft. '
Physical Address,City,and Zip 21.REMARKS i
. 1\Jane eel I
Co ty �"'� Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2.Ce tit" lion: 1
(if well field,one lat/long is sufficient)
'5' 53' Loa N c t I q ' i a) W .2 ,7......,--
-1 --z"4-2
Signal ified Welt Contractor ', Date
6.Is(are)the well(s):)ertnanent or uTenrporary By signing this form.I hereby certify that the uell(s war(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC',02C.02 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or Xo copy of this record has been provided to the well urn .
If this is a repair,fill out known well construction information and explain the nature of the
repair corder#21 remarks section or on the back of this farm. 23.Site diagram or additional well details:
3©O You may use the back of this page to pmvid additional well site details or well
8.Number of wells constructed: 3 construction details. You may also attach addi'anal pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
I
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 IIfdfferent(eramp/e-3C200'and 2Cl00') constmction to the following:
1
10.Static water level below top of casing: (ft) Division of Water Quality,Info Lion Processing Unit,
If water level is above caring,use"+•• 1617 Mail Service Center,Ral igh,NC 27699-1617
11.Borehole diameter: (In.) 24b.For fniection Wells: In addition! to se ' g the form to the address in 24a
above,also submit a copy of this form wi in 30 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,Undergroun Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Rai Igh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Sunnlv&Injection Wells: addition to sending the form to
• the address(es)above,also submit one cop of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the'sour health department of the county
where constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013