GW1--04908_Well Construction - GW1_20240816

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WELL CONSTRUCTION RECORD For Internal Use ONLY
This form can he used far single or multiple wells
1.Well Contractor Information:
Rex Meadows 14.WATER ZONES
FROM TO D€sCRlpTroN
Well Contractor Name ft, ft.
2113-A
*E I [IflI]Ii11LL !I.AL CASINO(ear multi-cased 'rvd8)OR LINER if
able
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. 1 ft- C( ft. Lc I 1 In.
Company Name 16.INNER CASING OR TUBING(geothermal dosed-1
1.4111 t41il)rtion'terrrth 0: 2[' J 4 1111 •' 10 ft , 111ER NIL Ilt s mA QuL
Liss all applicable well construction permits(i.e.County.Slate.Variance,etc,)
ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM To DIAMETES SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft H. la.
OGeothermal(Heating/Cooling Supply) esidential Water Supply(single) R tt. In�IR
❑Industrial/Commercial ❑Residentia!Water Supply(shared) IIRI_ _
MTER I'O IAL EMpLACENFNMS-rBOD4k AMOUNT
()Irrigation �eNon-Water Supply Well: -x( rt. C. A b ill ` ill ) (1
()Monitoring ❑Recovery r'
Injection Well: ft. ft.
❑Aquifer Recharge ()Groundwater Remediation 19.SAND/GRAVEL PACK(if appricabk) -
❑Aquifer Storage and Recovery OSalinity Barrier , FROM - TO MATERHGL EMPLACEMENT METHOD
❑A uifer Test ❑St h• ft.
q ormwater Drainage —
()Experimental Technology ()Subsidence Control 4• ft.
20.DRILLING LOG(attach additional sheets If necessary)
OGeothermal(Closed Loop) OTracer FROM - 7'O DttsCRFmoN(cater,hardness,.MUreek type,grain,Re,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) ` ft, ft*
nCA T CIA'
r_L
I . e.
C, ''11 q FL ft. r 11
4,Date Well(a)Compkted: D ol1 Well IDtt
5a-Well Location: :JZI D• 3 ft• (Q
t 'Yl t f ) ( l L� 32-2- H. yp5 n- Cyr-cent-le
ft- ft•
Facility/Owttc Natra Facility ID#(if applicable)
•
;o Ii)�fre. .fRd , Wenveh,�(Ie i'Vl, — fL . — .
Ph ica)Address,City,and Zip C
�r)e �15w i FC 039- -s1.REMARKS il•
County Parcel Identification No.(PIN) _ -' -am.
3.l.
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22:-Cer ilcallon:
•
:. )�)° 4---1 • b y N - 3SI- - ( a �`f�; , 1 (
• W
Si use of Cenifed Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary
By signing this form. 1 hereby cmn(f,that the»elks)was(»erel constructed in accordance
7.Is this a repair to an existing well: IIYes or [�T�Yo with!SA NCAC 02C.0100 or ISA NCAC OIC.0200 Well Construction Standards and that a
�/� copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information d xplain the nature of the
repair rattler#2l remarks section or on the hack of thisftrin. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary,
For multiple Injection or um-WO rer supply wells ONLY with the same eautOrstetion,you can
submit one frirm_ SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: T 05 (ft•) 24a. for All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths 0-different(example-3 00'and 401001 construction to the following:
10.Stalk water level below top of casing: Lo (ft,) Division of Water Quality,Information Processing Unit,
If urner level Is phone casing,use-+("� 1 �( 1617 Mali Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: "`' ' (in.) 24b. For Injection Wefts: In nddi,:Ion 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: ( #,.(✓ construction to the following:
(i.e.auger,rotary,cable,direct posh,etc.) l
Division of Water Quality,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ,--) 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) c-% Method of test: % ^� 24e.For Water Sur)nly&Inlectiost Wells: Zn addition to sending the form to
the address(cs) above, also submit one cony of this Esern d;.I,:.. 141 .,..._