GW1--04096_Well Construction - GW1_20240712

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple welt
I.Well Contractor Information: .
Rex Meadows 14•WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 1t ft.
2113-A ft. R•
NC Well Contractor Certification Number iS.OUTER CASING(for k4cased wells)OR LINER(If applicable)
FROM TO DIAMETER THICKNESS MATERIAL -4
Clearwater Well Drilling Inc. I ft ,��J R. Li.,),i tn. (?ve^
Company Name 16.INNER CASING OR TUBING(geothermal el d-loop) r
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: rt. rt. In.
Uri all applicable well catntruction 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
DAgricultural °Mtmicipal/Public ft. s is
OGeothetmal(Heating/Cooling Supply) tesidential Water Supply(single) R R. to f
°IndustrialComme/cial °Residential Water Supply(shared) Ia.GROUT
FROM TO MAtIRIAI EMPLACEMENT &AMOUNT
Non Water Supply Well: ,
ft. ft.
QMonitoring ❑Recovery
Injection Well: n. n•
DAquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK(if apptiaJrle)
FROM TO MATERIAL EMPLACEMENT METHOD
[Aquifer Storage and Recovery ❑Salinity Barrier R. ' It.
°Aquifer Test OStormwater Drainage --
ft. ft.
°Experimental Technology °Subsidence Control 20.DRI LOG(attach additional sheets If aeeary)
°Ge thermal(Closed Loop) °Tracer FROM To
m
DESCRIPTION(trMy NrdaattreWr.ck WW1. en.etc-)
❑Geothermal(Heating/Cooling Return)l °Other(explain under#21 Remarks) \ ft. 110 R' `n ��A y'f 'C-i-
4.Date Welk')Completed:(o-to aq Well IN
Ct fL ll)lt1o>>R ,�1r�, .� 1�
+ ` tom . n ^ft. ) n. cuiLP
5a.Well I"idiom grown Have, I i1i'T ' es
ix _ 1 .-, C� r au.,°' t"s- n' ��,�(t
,o\e) 4"; FL R.Facility/Owner Name l_ rHe.C\e.rDS Facility IDiI(ifappileable)
IL IL I.:. r'.
' tct e3 ,id9c: Rd . Ma�'SI .tt R. n. 1 1t .I:!'CIED
Physical Address,aty,and Zip
:I.REMARKS lJ�; 1 2 Z0�4
I'1( ►S(
County Parcel Identification No.(PIN) �,.:'4-h ,»-''.e �:_Y
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: ation:
(if well field,one 1at/tong is sufficient)
`� 5 i` N FT 4-4 W -1-___,,_ 0l9- y
S. of Canfield Well Contractor Date
6.1s(are)the well(s): Permanent or 17Tetnponry gy signing this fora.I hereby certifr that the nell(s)mu(mere)conslntcted in accan/on e
with 15A NCAC 02C.0100 at I SA NCAC 0.1C.0100 Well Construction Sueutbrds and that a
7.Is this a repair to an existing well: ❑Yes or ckio copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under VI remarks section or on the hock u1this 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
ruhmit atefarw. SUBMITTAL INSTUCTIONS
9.Total well depth below laud surface: '10 15 (ft.) 24a. for All Wells: Submit this form within 30 days of completion of well
Fbr nndtiple wells list all depths if different(example-3 00'and 2@l00') construction to the following:
10.Static water level below top of casing: (co (ft) Division of Water Quality,information Processing Unit,
if water level is above casing,toe"t" 1617 Mail Service Center,Raleigh,NC 27699-1617
``,i i c
11.Borehole diameter: lL' 1 tl (In.) 24b.Fqr Infection Welts: 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: rotarki construction to the following:
(i.e.auger,roury,cable,direct push,etc.)
Division of Water Quality,Underground injection Control Program,
FOB WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test•. 'RI C' 24c.for Water Supply&Infection Wells: ip addition to sending the form to
(� c the addresses) above, also submit one copy of this form within 30 days of
n
13b.Disinfection type:l �1Qn it Amount: -1 C'C e J 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 Jan.2013

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