GW1-2023-01085_Well Construction - GW1_20230126

WELL CONSTRUCTION Rr'CURD f
n,H roan can be usett for single or tnaltiple Wells II
For Internal lJsa ONLY:
I-Wets Contractor Information: i
Rex Meadows 14.wAreR zoNRs
WellCnnlrnetorNartte mom m nascrtlPrlON -
2113-A rr.
t1• 11. 1
N(=WeIl Controetor Ccrtific,uio.W rnbcr IS.OIrI•Ii;R CASING rttrn led We&ORyi�rR ,t
Clearwater Well DN(ling Inc. " 70 i rITFR THECIWRFa MATERIAL
Company Name O' � � in.
-tom I&AMBRCASWCOR?UBINC dorral-lbe
z•We11 Construetiort Permit#:�_(— —�l M�sq FROM TO UiAMiit'gR TNICKNggS MA79RIAL
I.icl all gPl,Ncahlr xn/)camn'DetlnnPe,nnrr(le.Carmot S(gre,Parimlee•ele.) O• ft
3.)yell Ilse(ebeelr well uge): ft. R
Wafer Supply Welt: 17.9CMEN
MGMSLOTSiM 1KNFM MATE L TO IIL►ME76R TNiCRIA
►3AgrimtImrat pMtmicipal/PubGc R• ft. ia,
130tothetmal(HeatinglCooling Supply) Mesidemial Water Supply(single) ft. O. In.
❑industriai/Commercial O1kesidentia[Water Sn i shnred)PP Y( ta.GROAT
girri lion TERM" TO MATRRUL RMtLACRM &AMOIINT
Non,Vyater Supply Well: ft R.
13Monitoring pRecovery rt ft.
Injection Welt:
f_iAquiferRecharge 0. A.
RGiormdwater Remedintion IR SANDMMAVRL PACK f e❑Aquifer Storage and Recovery [Salinity Barrier FROM TO M1IAT8RiA4 RMPLAC8MRN7 MRTROR
t3Aquifer9eFt D&MMwater Drainag e n• rr.
0EXPcrimentalTechnology 17SubsiilenceControl
MGeothermal(Clased Loap) pace. xtk 11131ILLING LIIG addt8nul�ttea1s11 neea»ra
OGeothermal Heatin Conlin Reitim !]other lainunder#21 Remtrrks FROM To U&gCRiP7tON mlai searmek a etc.
4.Date W01(g)Cam cted. n �� A
4'is-a.Well Locatlan: 1 (C�-- O• O•
raggaylowne,Nam R p rc , � n) ,,.,
r Facility ID//(ifnp litatbic) t VI✓� p 1
P Rica]Add tas4,Ctty,and Zip (� r ft• T'° ' 1S S .±) -a
21.
Cmmty j,
Pamml identification No. P
56.r,aHWdca ( �)
and Longitude in degrees/mrnutett/seconds or decimal degrees:
('£well field,one]0ma is au07cicat) '1r1n
2 Certl Arlon: 1ri�i3tYY}3if�;( ea],'7 Uf'k
6,is(are)the well(s):*P M-1ftent or OTemporary St [et►feenifred Wcli Co ntractor rle- to--'
7.Is this are i , \` ltj,signing Als fornr.1 h
pa r erein•rrrrrJp ,xe/I(s�n as(nsre),�rnarrmrrrl to an eltisting well: ��•� or �10 wirh J]A NC rtC pIC.010D o Prrmfdr JSA NCS rhar Ora i»nrtnrylmrrt
C 02C.0200 We"C)mv,'crin»Smndardc Ind Mat a
llrhic tc n repair,fl/M,1 homer►well cnnclnrellan lr�ormatlan a cap]•afrhts rrca,•r//�htK'rt ed tolhc aril nxmer:
rrpn/r under 021 remar6l archon or Olt0e IMknfMIJ21ltn. nd eglain the armor rifrhe
23.Site diagram or additional well dedalLq:
H.Number of we&constraeted- 3-3 M f- Q- a$S y You may use the back of this page to provide additional wall site details or well
Fnrmrdrtplc I,r/ecrirn�a'aon„rarer en constriction detaiN. You may alsn attach additional pages if accessary
suhrnir one,Jnr:n. pldY++�Ds ONLPn l/h the some eanprnertnn,�vn ran
SUBMITTAL 1NSTUCTiONs
'1.Total wdi deth b
depth land amfsce:FOP nuamplc uxlh/Lsr nG r/ r/ao i d' ( p y e1r !![!Error cram is 3 OD'm,d2Q1D05 (f•) 24a.IFeIr A^ l�Wt•Jta: Submit this form within 30 days of completion of well
I0.static water level below top ofcasing: constnt,tiotr to dtc following:
i
r/'amrra•lrrellrahmc rgs7n/;,t,.4C"t" (ft.) Division of Water Quality,Information Proc ging Unit,
l[.Borehate diameter: 1617 Mail Service Center,Etnieight NC27699-1617
(1Q) 240. or In+xNi ells In addition tolsending the form to the address in 248
l2 Wen construction method: aloe, also submit a copy of this form wi{l1n 30 da.
(i'c'auger-mtnry,cable,direct push,etc,) construction to ate following: A of completion of well
B)R WATER SI)PPI.V WELLS ONLV:
Dhi.4lon of Water Quality,Underground injection C'ontral Program,
163E Mall Service Center,Rol'elgh,NC 276991636
13a.Vicki Glpm)
Method of test: 24e.for Water Snunty&Inie�-`Inn Weu� II addition to sending the form to
13b.Disrnfeedon type: the gddmrq(ea)above,also submit one col
Amount: COMPIC6011 Of well Construction to the ccimtp help), dey of this partmenit of thein 30 account
where constructed. 4 Y
Fm u,GbY.t
North Cnmtina Department of F.nvimninent and NDfInHl ReMfimcs•Divisinnof water Qaalitg l
i Ravised An-201A