GW1--06192_Well Construction - GW1_20241021

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WELL CONSTRUCTION RECORD For Internal Use ONLY: I
This form can be used for single or multiple wells
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1.Well Contractor Information: `^
Rex Meadows 14.WATER ZONES ' I 1
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FROM TO DESCRIPTION I I
Well Contractor Name ft. R.
2113-A ft. ' ft. I I.
NC Well Contractor Certification Number lS:OI EIECASING(tarmnitt-cued waite)ORIlit�It(Ifnpplkttbie)
FROM TO DIAMETER THICKNESS 11 MATERIAL
Clearwater Well Drilling Inc. I n 1-1-0. IF. ' t s�.`2 in. ' MATERIALI EDvk •
Company Name 16.INNER CASING OR TUBING(g_eothermal elhsed loop) %
6 c� _IRON TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 1 CJ\'3DD re. ft in.
List all applicable well constntclton permits(1 e.County,State,Variance,etc.) - •
fi. ft. ' In.
3.Well Use(cheek well use): I7.SCREEN i•
Water Supply Well: PROM TO DIAMETER SLOTSi=R THICKNESS MATERIAL
()Agricultural . ❑Mwticipat/Public ft. IL In.
()Geothermal Hea' Coollrt. II. In.
trttg! ng( Supply) l�ftesidentiel WaterSuppiy(single) ,
Dlndustrial/Commercial DResidential Water Supply(shared) 6lg CatDEr TO MATSRiAL EMPLACEMENT METHOD&AMOUNT
El Irrigation t R• rl0 R• c�_n-- IM1 1 1i /t.&i
Non-Water Supply Well: ft.
eat
()Monitoring ()Recovery ft.
injection Weil: • ft. n- I •
()Aquifer Recharge °Groundwater Remediation .19 SAND/ORAVIL PACK Of applicable)
❑Aquifer Storage and Recovery ()Salinity Barrier 'FROM TO MATaRlAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑StomtwaterDrainage, ft. R.
DEXperlmental Technology DSubsideoce Control 20.DRILLING LOG Moth addition: abeetsif necessary)
ElGeothermmal(Closed Loop) ()Tracer FROM TO . DESCRIPTION(color,Written,mi ks&ippe,ar9lp size,etc.)
°Geothermal(Heating/Coolinnng Return) °llOther(explain under#21 Remarks) ii'1 ft. (4[) tl. sans' M— i li t
4.Date Wells)Completed:�"1-t�5�Well ID# d R. �`�� r i 1 Imo'
,-,:-.1.. tb �UI .
Sa.Weli Locat
ion: DE H.
. 9ic-rui-Iftet r._ _ ___. ___,_ ..__,
Paoility/Owner Name Facility ID9(ifapplieabie)
ft. ft
3� ��►1 nl t►�, � , �u�n i Ile, ft. ft I OCT 3 1 2'024
Physical//�•Add)d/rress,City,and T.tp N t✓ 2L REMARKS I
ratioI ('.:'�.�.. <�_!.;.
C ty Fame!Identification No.(PIN) -
1'
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 4,.Corti on:
(if well field,one int/long in sufficient) t .
35' t-6°a5'3 N a` g ' 5� W .....A___,..------- q -o�lo 0q,
n Sig of iced Well Contractor Date
6.is(are)the well(s): Xermanent or ()Temporary By signing thin form.I hereby wilt that the wells)was(were)eoimtructed in accordance
with 154 NCAC 02C.0100 or lSA NCAC 02C,0200 Weil Constnrcllon Standards and that a
7.Is this a repair to an existing well: ()Yes or WNo copy ofthb record has been provided to the well owner.
If this is a repair,fill ant known weft construction nforma:nn and explain the nut.a ofthe
repair under#21 remarks section or on the back of this farm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional wall site details or well
8.Number of wells constructed: construction details, You mayalso attach additional pages if necessary.
For multiple injection or non-water.supply wells ONLY with the sameconstrnctlon you can
submit one form. +� \T SUBMITTAL iNSTUCTIONS
9.TotaI well depth below land surface: �7' '5 (tL) Trig.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd([/hrent(example-3@ 1000n0''and2®100`) construction to the following: ,
10.Static water level below top of casing: l..0D (ft.) Division of Water Quality,Information Processing Unit,
U water!eve!it above casing,Ise"+^1 p- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: kg L l) (in.) 24b.For in'action Wells: In addition to sending' the form to the address in 24a
/t� / above,also submit a copy of this farm'within 30 days of completion of well
tion
12.Well construc method: tar y construction to the following:
(i.e.auger,rotaty,cable,direct push,etc.) 1 1 .
Division of Water Quality.Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Rale! NC 27699-1636
13a.Yield(gpm) 05 Method of test: R1 q 24c.For Water Siumly&InLectfpat Webs: in addition to sending the form to
the address(es)above,also submit ono copy of this form within 30 days of
13b.Disinfection type: Amount completion of well construction to the county liealth department of the county
. where constructed. `I
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water(N(Nudity Revised Jan.20 IS
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