GW1--03203_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. it.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. // ft. l 3 ft- t a in. �l
Company Name �,y+/�J /�J 16.INNER CASING OR TUBING(geothermal dosed-loop) /
2.Well Construction Permit#: .212 / D04 7 5+ FROM ft. TO DIAMETER THICKNESS MATERIAL
ft. in.
List all applicable well construction permits(i.e.County.State,Variance,etc.) --
ft. tL in,
3.Well Use(check well use): 17.SCREEN —
Water Supply Well: FROM TO DIAMETER ,J LOT SIZE THICKNESS MATERIAL
H. ft. in.
C3Agtieultural LIMunicipalIPublic
❑Geothermal(Heating/Cooling Supply) f ktesidential Water Supply(single) n ft' In.
❑industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
FROM TO MATERIAL t EMPLACEMENT METHOD&AMOUNT
❑Irrigation / ft. ,q0 ft- ei fnC�V J T `/ `1�E /
Non-Water Supply Well: /1
ft. fL
0 Monitoring O Recovery —,
Injection Well: ft. ft.
OAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applcable) ,
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier ft ft.
❑Aquifer Test OStormwater Drainage — 1
ft. ft.
0Experimental Technology ❑Subsidence Control
t 20.DRILLING LOG(attach additional sleets if necessary)
QGeothermai(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock npe,grata size.etc.)
❑Geothermal(Heating/Cooling Return) OOther(explain under 421 Remarks) j ft, /35 ft. -`j' ,4,34'/ y- ( pi-
/15k a7�ft- CDl LI l Ae
4.Date Well(s)Completed: a a Well ID#
5a.Well Lo 'on: I. Z)4 lJ( j1&2,7V.7 i lft. O 74 Z/ Y
l�/� Pco,o_aA74.
27 7 =305 q7l?,, / :�,-- - }•
gl iii /hilt 1,4 s'il-L ,,5 ft. ft. rat f,.
Facility/Owner Name Facility iD#(if applicable) R n
5)/42 E31,(•K- I)/'//t ar, La' eS AX-j ft. ft.
Phys,Icfl Address,City,and Zip 21.REMARKS
County Parcel Identification No.(PiN)
4
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certi / on:
(ifwtellll field,000nne llallonnais suuffficient) �j (1 / e
J t`�`i 'v V N Si7f t 7! 2 W Sig ate of Certified Contractor Date
6.Is(are)the well(s):)Permanent or OTemporary Br signing this form.1 hereby cecil/I'that the ne/l(s)our(urrel constructed in accordance
with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or l No copy of this record has been provided to the hen owner.
If this is a repair,fill out known well construction information ant rplai n the nature of the
repair under#21 remarks section or on the bock 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 mach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one fnrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 3L,X.5 (fo) 24a. For Alt Wells: Submit this form within 30 days of completion of well
For multiple wells list all depots if di,gerent(erample-3g 200'and 2@l007 construction to the following:
10.Static water level below top of casing: (. CIf (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,lee"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
J
11.Borehole diameter: /P /IF' (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
` /,/ y above, also submit a copy of this form within 30 days of completion of well
f
12.Weil construction method: 0 /C -1 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) f _-i Method of test: 24c.For Water Supply&IniectiogjVells: In addition to sending the form to
t the address(es) above, also submini 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(iW-I North Carolina Department of Environment and Natural Resources--Division of Water Quality Revised Jan.2013