GW1--03170_Well Construction - GW1_20240524

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
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2113-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-clued wells)OR LINER(if aepttcabte)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. ft, ' ft. - in. r ,
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) 1
FROM To DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in. —1
List all applicable well construction permits(i.e.County,State,Variance,etc.) _ I
It. ft. is
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft, in.
❑Agricultural °Municipal/Public
°Geothermal(Heating/Cooling Supply) / Residential Water Supply(single) R ft' In.
❑Industrial/Commercial CI esidential Water Supply(shared) 1&GROUT
FROM TO MATERIAL EMPLACEM►ENT
�M HOD&AMOUNT-I
Non-Water
ft. �� ft. ( Yet 1��V �K�
Non-Water Supply Well:
ft. ft. i
OMonitoring ❑Recovery I
Injection Well: R. ft. _ 1
°Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL, EMPLACEMENT METHOD❑Aquifer Storage and Recovery ❑Salinity Barrier it. ft.
❑Aquifer Test OStormwater Drainage R. ' ft.
❑Experimental Technology °Subsidence Control
20.DRILLING LOG(attach additions]sheets if necessary)
QGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(calor.hardness tsolt/tock tfpr,grain size,etc.)
❑Geothermal(Heating/Cooling Return)�}°Other(explain under#21 Remarks) 1 rt. .Vr J ft. can (;�9„(_ �,,�` t
4.Date Well(s)Completed: Cl? A) e111D# MU� ft �)'L) t. (Irani
(TJ 1
..s/y ft. r y'! i l R• 11/ ,t)l„X _
5 ,Well Location: ` ft � ft TiLifu-i-c.
1.1t �f ) �\‘� k. ft. Z . i.,
FacilitylOws rName Facility ID#(if applicable) ft ft.
//O vc Al -,Q 91, /' '.c tom° I (1;, fL ff. 1` 2024
Physical Address,City,and Zip 21.REMARKS "r"
lJa
County Parcel identification No.(PiN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2. odor:
(if well field,one latilong is sufficient)
`S' / ;1' ' N ST.'{ / a f_ j w .,'i ./' 0 I �la-'
Sig um of Certified Well Contractor Date
6.Is(are)the well(,): ( 'ertnanent or OTemporary 8y igning this firm.I hereby certii,than the well(,)ttm (were)constructed in accordance
with ISA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: Oyes or NO copy of this record has been provided to the well owner.
If this is a repair,fill out knoun well construction it formation and explain the nature of the
repair under x21 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-mitersttpptb ells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: a4S (ft.) 24a. For All Wells: Submit this 'form within 30 days of completion of well
For multiple urns list 411 depths lid berent(example-3(a 200'and 2tf100') construction to the following;
l4.Static water level below top of casing: (VC (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing.use"+"t 1617 Mall Service Center,Raleigh,NC 27699-1617
(
11.Borehole diameter: ty' I (ia) 24b. For Injection Wells: In addition to sending the form to the address in 24a
�� above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 1 D+.Q. 1 �1 construction to the following:
(i.e.auger.rotary,cable,direct push.etc.) ll
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY! 1636 Mail Service Center,Raleigh,NC 27699-1636
r /'
13a.Yield(gpm) Method of test: JIC( 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the addresses) 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.
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised)an.2013