GW1--04122_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD For internal Use ONLY:
This fora an be used for single or multiple wells 1
I.Well Contractor Information: 1
14.WATER ZONES
Rex Meadows PROM TO DESCRIPTION
Well Contractor Name "—
2113A It.
IS.OUTER CASING(far multi-cued wells)OR LINERiirs
NC WeilContrtact%CsnifisetioaNumber ! tz? _i o I DIAMRTan,, ,THICKNESS MATERIAL
Clearwater Well Drilling Inc. t; n.170 R.r(�%s= in. n l-L,
>,.
Id.INNER.CASING OR INC(geothermal closed-loop) 1
2.Wen Construction kere,tt u:
CotttpanyNaane PROM TO DIAMETER T1tiCKNESS MATERIAL.
��p . r �5j t I it in.
_..¢� . r r_ . �..�.�.,
List all applicable well cau:ruction permits(i.e Camay,State,Parlance,etc.) ft it. _.___...
3.Well Use(check well use): 17.SCREEN —
t«uOlt__i TO _._i w,,�tt rSR..., s►.oirsIZK ' nttctt.cEss`,M.ATraiIAL
Water Supply Well: ft. n• I taa,
°Agricultural °Municipal/Public is
OGeothemtaF(lieatinglCooting Supply) tkRcsidential Water Supply(single) 9 RCr LEA
Gln-htstriaVConnnercial C)itesidential Water Supply(eland) p'f 1.o . stATtsREAi. Ea t{ d►A•mu,i*_r
f It tg6 R• ,i1V�f 'p/x e(/
Clhsi ion ___. ___ -,a.,..
Non-Water Supply Well: IL n.
❑Monitoting ORecovery . .
f. it. l
I°Aquifer Recharge °Groundwater Rr:anedialicee' #y f NDIG ua t PAMT,:(itsgpka
MATERIAL f EMPLACEMENT METHOD
ClAquifer Storage and Recovery C°Salinity Barrier Mt. tt �_--.--- -_--.
iaalttt� - — •
ifer T+a ttStcxraY.ester Drainage
It to i a
t
ilbttr+erin%entsl-technology r:insicget:ce(.onos • � ,i 20.DP _. =i-vE3�=i?ecit ndi?l0o:.0 sheet e" ermrylr-
OGeothetmal(Closed Loop) °Tracer III=IIIIIIIIIII To uEscsitteTto_N 'trlr�au�t,e, 's tr nre,grata me. .),v..1
OCst outer i(licatine/C oolina Rzttit ) �C004her(explain uti4a/121 Rm.:luris) . rj7 • )Io f' < I7o i 1...th _ .i
_.flute Well(s)Comp+ lct_ed: (y-1�-t�7; eE 1Ot) /'._ - I0 ,�/6°11 r le -- �-a•—�.•v ,
St
5a.WYll h eat er. P ell oVu7Or► Vu? Ely I Q.iiiie L_.__.. #
a- is‹�-- Nair hot 1 Slone, n.
Facility/Owner Name facility IDS(ifryapiicabki) ft 1 n. `c 1.-I N/E D i
excrrl C' - r V'V vzi- I I/ 7AJC --_� 1 i
(:. ,i 1 JUL 2 � 1
Physical taddress,City,and Zip -
.
ALf IliA he) Ittl�ftv+F �'tr'"��r 'F`'�" 1
County Parcel WOW-tendon No.(PiN) afiritsti7. V
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22. erti flea: l r t
(if omit field,one lat./tong is sufficient) of
t35 (.
S lute of Gasified Weil CdnnactorT Date
6.Is(are)the well(s):)(Permanent or QTesepot'at'y By signing
dots form.I hereby cart&that the nei(s)ens(sere)constnacted in accordance
////���\ with 15A NCAC 02C.0100 or iSA NCAC.02C.0200 Well Construction Suaidards and that a
7.Is this a repair to an existing well: OXla or
,.y11 copy aft•§is record has been pr.t*(ed to the well owner,
If this is a repair,fill out hum;nen coxrtracrr it information and lain the ruttaarar of the me diagram or salttitisita)well details:
repair under fi21 remarksrction or on the herek of this form 23.You may use the back of this page to provide additional well she details or well
6.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For.,•'.ram err y t-gt-.....,...,,,..,,,,-,,,.n.,r,..-oh curs-r.?ot, rem:intIA vedg!q}'e•3 ton
StilibilTIAL iNSTttt,Ttt
submit onrjera:- /n !
9.Total well depth below land surface: L '. (ft.) 24at. gor Ali Welts: Submit this fonn within 30 days of completion of well
For inullit is wells list ail tteadis ir<GRerent(aimu fe-30j.20N{0 old 2(d:100^r 1s.dcuction to the following: Quality,
or (It.) Division ref Water
4 o ter le vet
ex ale level s.tbelow -+its rasing:: =L _ . -._.._�.:_ .-::::.;., :i�...•:
?J outer rears a arxr�crcrrrx.tar-/T,-,t
t t rt,.rPh"to.tl%,meta.- O 'ff ftw t 24b.For Injection Welts: In addition to senthno the forms na thc atddress in 24a
---. �' d3v n,an ir..irinss ii ti+ij j ea. ;bk. au-A.: ..'+..-i;;;;;;it;:./A v.+tidt :a 55 i
.
rotary ma:ilea Mille iitllowintr
.. �.�:>_�-.�.,�, „oh,*„oh,* _
(ere.soaps,lotaty mbia,direct P we-) Disbar of Water Quality,Uudergroantl injection Control Program,
-.-- t ♦C+f....- a.�__tN...f.__n�-s•T^•.L--a s`•aneM 46tG
i t:._�...T'A ii ii.R C"•e�rj.T Rw..i..i..i.i.UriL:e-. . ...... -.- ..- _ -. _
5 �i I7a- c.._s�;_.--Rimed,:p_t- re-rtt Ne*c In att'('�irot tr. ':':i�ertL kti trs
1 ice.i ii iYur iTizie-.u••-==- ^'7 the address(es) above, also submit one copy of this form within 30 days of
I completion of well construction to the county health deportment of the county
toed ?".4nrwH.w..11140.0• 6wwewF... i rifsacazrrrsirriini-
Rum O{V.l North Carolina C7epattmcan of tnvarontnrnt and Natural Resources-Uavisaan of Water ajamaaty
Revisers i.e.aii3