GW1--06330_Well Construction - GW1_20241022

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form call be used for single or multiple wells I
1.Well Contractor Information: .
Rex Meadows '14.WATER ZONIS •
FROM TO _ DESCRIPTION I
Well Contractor Name ft. R, I '
2113-a ft. ft.
NC Well Cotitractor Certification Number ;5:OUTER CASING(Nor multi-cased wells)OR LINER Of no ble) ,
PROM ' TO DIAMETER THICKNESS l MA
Clearwater Well Drilling Inc. _ /' f' �342 ". 14. & i I I 1 .
Company Name lc INNER CASING OR TUBING(geatiternml dosed leap)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well ConIstructlon Permit#: R. iI. ,In,
List all oppliaable well constnactimu permits(Ie County,State,Variance,era) fL ft. In I ,
3.Well Ike(check well use): ,iT.SCREEN i '
Water Supply Well: _MOM TO DIAMETER _SLOT SIZE THICKNESS MATERIAL ,
°Agricultural ❑Manicipal/Public - ft. II. la.
°Geothermal(Heating/Cooling Supply) )Residential Water Supply(single) n' U' In.
❑industrial/Commercial ❑Residential Water Supply(shared) 4* OUT TOPROM MATERIAL EMPLACEMENT METHOD 6cAMOUNT
El Irrigation . A`7' ILNon-Water Supply Well: - / ft ��� . / /' Ur
ft. ft. ,
❑Monitoring °Recovery '
injection Well: • it, it. i ,
❑Aquifer Recharge °Groundwater Remediation ..09.SAND/GRAVEL PACK Of appllcahle) I
❑Aquifer Storage and Recovery LlSalinity Barrier PROM 1 TO MATERIAL I EMPLACEMENT
fb ft.. •
I •
❑Aquifer Test OStonnwater Drainage -
lt, ft.
❑Experimental Technology °Subsidence Control
20.DRILLING LOG(attach additional sheata.If eeCalsary)
°Geothermal(Closed Loop) °Tracer FROM TO . DESCRIPTION(color,hpzrdnras,mil/reek type,Ereta size,eta)
❑Geothermal(Heating/Cooling Return) QOther(explain under#21 Remarks) / It 3(44 R' S( )4' /�
4,Date Well(s)Completed: 9— Ri‘Well ID# -- ft, ��� H•' 4� TC!
•
3,a R• 2/3 ft, .(z' &jZ.("
Sa Well Location: 3/3 le' 5R. (p /,,I
L )ram ("mo( / (1. tY. f�/J
Pacility/O4tc
ame Facility 1Dii(ifapplirable) , ij 4. : .T t, --1
3 ( I0 I// /g� . ft. IL O f1T 2 2 7 f 74
Physical Address,,City.
.aand
ZiZip 21.REMARKS I
/147/1 Yi
County Parcel Identification No.(PIN) o.i•u`_`,i.,-.i
iY..
Sb,Latitude and Longitude in degrees/minutes/seconds or deeitnal degrees: 22 Cos on: •
(if well field,one Int/long is sufficient)
:35 � "()TO N V 35 3ST W � _ /L, -' 9-/ 2 '
b
11 Si . Certified Well Contractor Date
6.is(are)the well(s):�1�Permanent or ❑Temporary By signing this form.I hereby ea*that the wells)was(ware)rm sst ucled in accordance
with ISA NCAC 02C.0100 or ISA NCAC 0,2C,020D IF It Construction Standards and that a
7.is this a repair to an existing well: °Yes or ii io copy of this record has been provided to the well owner.
I this is a r f trpat,fif!out!mown well construction i>rfa•mar(an mid explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide a ditional well site details or well
B.Number of wells constructed: construction details. You may also attach additlo I pages if necessary.
For multiple Infection or non-water supply wells ONLY with the same construction,you can submit one form, SUBMITTAL WSTUCTIONS
9.Total well depth below land surface: �e_P_S-- (ft) 29a.for Ail Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths i(d 9erent(example-3(o)200'mrd le. 0) construction to the following: •
414:10.Static water level below top of casing: C.Z t (ft.) Division of Water Quality,Information Processing Unit,
if water level is above casing,use•'+" t • 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: CJ!/ (in.) 24b.Fir In Wells: In addition to sending the form to the address in 24a
/� ,y� above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: rC/i 17/ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Quality,Underground I action Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleig NC 27699-1636
13a.Yield(gpm) 3 Method of test: PIO 24c.For Water Sunnis&Infection Wells: In a�dition to sending the form to
f�
I.t the address(es)above, also submit one copy of this form within 30 days of
13b.Disinfection type tIA/)1�,'L Amount: b I completion of well construction to the:county Health department of the county
where constructed.
Form OW-I North Carolina Department of Environment and Natoml Resources-Division of Water Quality • Revised Jan.2013
• 1

•
Will Meer Sall64bout CalaImam
Owner,,T efrObt) NewWelt,_
Moires&3)2 //fors' (3,ove eaf, ggpair 1
Panit
I hmeby certify-Olathe abovereferenced weR vatt grouted in appeeinnce in with
all CountyWellnies.
well millerlfdi
Caditcate#: 02//53 Dole,Grouted;
construesc. LcIIt •
Total Depth;
Caling TYPe: Thifinesa: rri-47
Cane's*: 3(P Witt c"?
Diameter:, /8F 14)al7
Height
Drive Sham
GPM:,