GW1--04932_Well Construction - GW1_20240816

WELL CONSTRUCTION RECORD
This form can he used for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information:
• Rex Meadows 14.WATER ZONES
Weil Contractor Name FROM TO DESCRIPTION
ft. ft.
2113-A
ft, ft.
15.OUTER CASING(far multi-cased well)OR LINER(If ap Ilcebte)
NC Well Contractor Cenificatian Number
FROM I TO DIAMETER f THICKNESS MATERIAL
Clearwater Well Drilling Inc. n. 7It"
Company Name 16.INNER CASING OR TUBINCT ermal closed-I.,, /
2.Well Construction Permit#: FROM TO DIAMETER THTCRN6.RS MATERIAL
List all applicable well construction permits(i.e,County.Stare.Variance,etc,) n It. in.
ft. ft. In,
3.Well Use(check well use):
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural LM� unicipal/Public ft.• ft n.
❑Geothermal(Heatirtg/Cooling Supply) v°residential Water Supplyft. ft. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO'}�
❑lrnga[lnmMATERIAL EMPLACEMENT METHOD @AMOUNT
Non-Water Supply Well: 7 ft. ACL/ ft. Zr/ / 4- n/I-4d
DMonitoring DRecovery n. n• J �1�/ //
injection Well:
ft. O.
DAquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(If applicable
DAquifer Storage and Recovery ❑Salinity Brinier < FROM TO MATEF FA L
EMPLACEMENT METHOD
DAquifer Test ft. ft.
❑Ster Drainage
❑Experimental Technology ❑Subsubsidenence Control ft. O'
OGeotherma}(Closed Loop) DTracer 20.DRILLING LOG(attach additloael'beets If necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) /FROM rt. .'7
To
S ft. DESCRIPTION feeler,hard. anturoca bac,grata'lac,etc.)
soma a,
4.Date Well(s)Compl tteyd�:s,,, Well 1D# ft. tt' g'.
�_5a.Well Location: '� '/LN!ca5 )r'4/ / C.. i sjv/Y, R. R, U.
Du S fl i� r!rC rr>t) ft. /
ft.Facility/Owner Name ft. '
/ Facility iD#(if applicabie)
!/Vter i'd9e Ed �. 1v fnn 1 rt. n.
Physical A jrTress,City,and Zip ft. ft.
H/jjr// ��
)0 - I 2t,REMARKS
CtwCounty /J/�/l // / Parcel identification No.(PIN)
f
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: — • I
Z2-Cts
(if well field,one iat/long is sufficient) MfibRHon:
N W 1, - . /-�
6.Is(are)the well 9; Ziignattae of Crnified Well Contractor Date
Q�
() t `Perresnent or ❑Temporary
By signing this for, l hereby certify that the urll(s)tins(were)rntn•tntcted in accordance
7.Is this a repair to an existing well: Oyes prjo with ISA NCAC OJC.01(N)or/S,t NCAC 02C.0200 Wel/Construction Standards and that a
If this is a repair,.fill ant knot,,,well constuction Information and explain the nature of the copy njthis recnl(1 has been provided to the well nnrter
repair tinder#21 remarks section or on the hack of dttshiritt23.Site diagram or additional well details:
S.Number of wells constructed: You may use the back of this page to provide additional well site details or well
For multiple injection or non-water supp/v wellsONLY with the same construction,port can construction details. You may also attach additional pages if necessary,
submit one film.
SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 70
For multiple wells list all depths if different(example-WOO'and 2 i0U (ft.) 24a. kbr All Wells: Submit this lone within 30 days of completion of wellD � construction to the following:
10.Static water level below top of casing: Division of Water g t,
ifwnier/ow is above casing,use•'+" r (ft) Quality,Information Processing UN
/ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:
(in.) 24b.For Iniec_tion Welly: In addition to sending the form to the address in 24a
12.Well construction method: ro ICt-ry above, also submit a copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) constmcrion to the following:
Division of Water Quality,Underground injection Control Program.
FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(pm) Method of test: 1R .
/ 24c.For Water SuDnt>'&tni€ction 1 e In addition to sending the form to the address(cs) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to !Fee county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality
Revised Jan.2013