GW1--00557_Well Construction - GW1_20240125

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form canbe used for single or multiple wells
1.Well Contractor Information:
Rex Meadows 14.WATERZONES I
FROM TO DESCRIPTION I
Well Contractor Name ft, ft
2113-A ft. ft.
NC Well Contractor Certification Number I5.OUTER CASING(for multt-cased wells)OR MINER(Rap Ileable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. / iLc..55ft. /0 ii?in. / 7Lr
Company Name -16.INNER CASING OR TUBING(geothermal clbseddoop)
2.Well Construction Permit#: /ROO?c3 O0,3 FROM fl. TO rt. DIAMETER in. THICKNESS MATERIAL
List all applicable well construction permits(i.e.County.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 OMunicipalPublic R. in.
°Geothermal(Heating/Cooling Supply) residential Water Supply(single) R• R. in.
❑IndustriallCommercial ❑Residential Water Supply(shared) 1&GROUT I
FROM TO MATERIALS/� //1 EMPLACEMENT
EMPLACEMENT METHOD&AMOUNT
❑Irrigation / R' C`© ft. rege t I /:16 c/
Non-Water Supply Well: It. ft.
❑Monitoring ❑Recovery
Injection Wen: • it. R. I
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(If applicable) I
❑Aquifer Storage and Recovery ❑Salinity BrinierFROM TO MATERIAL EMPLACEMENT METHOD
R. tL I
❑Aquifer Test ❑Stormwater Drainage -
l7Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)'
°Geothermal(Closed Loop) °Tracer FROM TO DESCRIPTION(color.hardness,^ soli/rockk rope.grain size.ere.)
°Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) / ft ft. s a_ (`/7
4.Date Well(s)Completed:/2 f5)..3Well ID# ft. />77 R. ( )y.-',q i k
177 ft. 17?it. �f.1 /tioa I
5a.Well Location: /7 L .c1,�ft. (ii/im�A
I
Facility/Owner Name Facility iOP(if applicable) R
9 C/t'v s Dr_ ( fdj , 1vc � F‘ sLL
Physical Address,
City,and Zip } l+
i- K 0//)h� 21.REMARICS 1�� ` e4 LU64.
County Parcel Identification No.(PIN) I firs ra.vil u`Oft7.70i a.9(jiq
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: c sari e tr:S.'ki
(if wellfield,one latlrlong is sufficient) s� /(� 22.CertiR on: 1
c >�ic�/ •`-t'��( N Sd I Wfri3w' W , /2',?v '.]
Si tutu of Certified Well Contractor ; Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this farm I hereby certify that the wells)l was(were)constructed in accordance
with 154 NCAC 02C.0/00 or 15A NCAC 02C.0200 Fell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Xio copy of this record has been provided to the well ovine
If this is a repair,fill out know,well construction Information and explain the nature of the
repair under 021 remarks section or out the bock 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 addit onal pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction.you can
submit onefonn. SUBMITTAL INSTUCTIONS 1
9.Total well depth below land surface: t)tg6 (It) 24a. For All Wells: Submit this form with n 30 days of completion of well
For multiple wells list all depths ifdiifferent(example-WOO'and 2©too') construction to the following: i
i
10.Static water level below top of casing: �(/f� (it.) Division of Water Quality,Infor ation Processing Unit,
If water level is above caring use•'+"/� (� 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: /0 (in.) 24b.For.Injection Wells: Ia addition to Befitting the form to the address in 24a
_ above,also submit a copy of this form with n 30 days of completion of well
12.Well construction method: /�n f T construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Undergrotmn Injection Control Program,
FOR WATER SUPPLY WELLS�J ONLY: / 1636 Mail Service i Biter,Ralgh,NC 27699-1636
13a.Yield(gpm) C�O Method of test: / 24a For Water Supply&Infection Wells: hi addition 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 county health department of the county
where constructed.