GW1--02135_Well Construction - GW1_20240409

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WELL CONSTRUCTION RECORD
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This form can be used for single or multiple wells For Internal Use ONLY: i
I.Well Contractor information: i
Rex Meadows 14.WATER ZONES i 'i
FROM TO DESCRIPTION;I I
Well Contractor Name n, R. I II
2113-A ft. ft' i,
NC Well Contractor Certification Number 19:OUTER CASING(for mull-cased wells)OR LiNER(If applicable)
FROM TO DIAMETER I THICKNESS MATERIAL
Clearwater Well Drilling Inc. I n• . 2.. ft. utt In•I I PVC
Company Name ilir:INNER CASING OR TUBING(geothermal dosed-loop)
FROM TO DIAMETER I' THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft; In.i
List all applicable well construction permits(i.e.County,State.Variance.etc.)
ft. ft. In.I
3.Well Use(check well use): • 17 SCREEN I
Water Supply Well: FROM To DIAMETER SLOT SIZE I THICKNESS MATERIAL
❑ cultural ft. f. to. I I
D unicipal/Publie
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 111.GROUT I
FROM To MATERIAL I EMPLACEMENT METHOD&AMOUNT
❑Irrigation I R• 20 II. CPCINefl•�- rI � -
Non-Water Supply Well: ft.
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❑Monitoring ❑Recovm'y ff.
Injection Well: • ft. it.
DAquifer Recharge ❑Groundwater Remediation 10.SAND/GRAVEL PACK(if appncable) I I
DAquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMBTHOD
IL rt. I' 1'
['Aquifer Test DStomrwater Drainage — ft.
DExperimental Technology OSubsidence Control 1
20.DRILLING LOG(attach additional sheets if seecssary)
❑Geothermal(Closed Loop) DTracer FROM TO DESCRIPTION(eabr,hardness,sorttroektype,grain she,eta)
❑Geo hennal(Heating/Cooling Return) 00ther(explain under#21 Remarks) I It �Z ft* wni a- t I ,y-
4.Date Well(s)Completed:3`5-Z Well iD# Z. ft. ��2(iS re>t. • /)n 1 IC]�t r
5a.Well Location: FASfL ,,�-, ()reknit_
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Rahf9r+- `)t ree s ft. i (J
Facility/Owner Name Facility ID#(if applicable) ft.
�1 � (gym Cr -, 1 kACU hall t� {.,. G 4 'Ij
ft. ft. _ '' "�I
Physical Address,City,and T.rp N� 21.REMARKS $F R to L 26L4
Vs.... ..
County Parcel Identification No.(PiN) tP.:C::,c 1•�: `,, +�":;li:ca
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: ,Certi ation:
(if well field,one latllong is sufficient)
5 I I N . 3y= 5�� W s—S—Zy
Sig ure of Certified Well Contractor Date
6.Is(are)the well(s):17kermanent or OTemporary By 'g this font.I hereby cer*ll, that the well(s)w i(were)constructed in accordance
with l5A NCAC 02C.0100 or 1 SA NCAC 02C'0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or )8(No copy of this record her been provided to the well owner.
If this is a repair.Jlil out known well construction information and explain the nature of the I, I
repair under#21 remarks'section or on the back of this form. 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 l'
submit oneform. SUBMITTAL iNSTUCTIONS
9.Total well depth below land surface: 1S.S (ft.) 24a. For AU Wells: Submit this form I within 30 days of completion of well
For multiple wells list all depths if deferent(example-ANON'OD
2(0100') construction to the following: I'
10.Static water level below top of casing: l i/l/ (ft) Division of Water Quality,ii(formation Processing Unit,
Ifwaler level Is above casing,use"+" 1 1617 Mail Service Center,lRaleigh4 NC 27699-1617
11.Borehole diameter: (Q I 0 (in.)' 24b.For Infection Wells: In addition'to sending the form to the address in 24a
above, also submit a copy of this form1within 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,Undetground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: � 1636 Mail Service Center,Ralelg I NC 27699-1636
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13a.Yield(gpm) v Method of test �t0 24c.For Water Supply&Infection ( 1 Wells: In ad Ilion to sending the form to
the address(es)above, also submit one copy of(this form within 30 days of
136.Disinfection type: Amount: completion of well construction to the'county health department of the county
where constructed. i
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised]an.2013

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