GW1-2023-01087_Well Construction - GW1_20230126

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WELL CONSTRUCTION.RECORD
Tn,..f"nn can m amen for single or multiple wells For internal llsa ONLY:
i•Well Contractor Information: l
Rex Meadows 14,WATER zoAB t
Weil CnniraclorName PROM TO D&SCRIP7tON
11• ft.
21 93-A �• �. 1I _
NC Weil contractor Ccrtitlention Number I&QU IER CASH ORIJ a
Clearwater Well Drilling Inc. FROM To DUM@TER T9iCKNM MATWAL
CompsnyName to f 16.1NNERCA9INGaRT1J111I1VG
t/\�._t--y,lJ� rmttiettned]oo
2,Well Construction Permit#: �' � FRt>flt To DiAMIfiiHR' TtitCKN63S MATt3RlAL
l frt nll4)rplicah/r,srll cnruh7rcllan pest Gs aCannotSlola.l�arlane a' it in,
3.Well Use(check well use); R fL in:
Wafer SaPP1y Weil: 17 SCRETN
FROM TO DtAMBT&R .BLOT BITE TtiiCKNESq MATBAIAL
17ngricithiral 13municipai/PubGo rr, n' 11h
I�Gemhermal(Noting/Cooling Sltllply) OResidendal Water Supply(single) ft. 0• In.
Olndustry'ai/COnlmerCial Mesidentini Water Su 1 (shared) I&GROUT
Supply( 'FROM To MATERIAL- nMPLACBM tNS7iiOD&AMOUNT
❑irri lion
Non-Water Supply Well: ft. ft.
DMonitoring QRecovery ft• fe.
injection Well: ft. fL
C1Aquifer Recharge M oindwater Remediation 14. GRAYBL PACK illfainimawth
0 Aquifer Storage and Recovery OSalinity Barrier FROM To I MATERIAL, RMPLACRWHTMETuoD
IJnquiferTest tt, rL
OSttirmwater Drainage
Ol:xirerimentaI Technologyp• O'
OSubsidenceControl
❑Geothermal(Closed Loop) DTracer 20.DRILLING LUG attach addlHeed a tSjr
[]GeothermalHearin Cooliq Return OOtiter lain antler#2i Remarks) FROM TO DESCR1PilON mtar ha troaltncA In ern
l� °• a75 ".
4.Date Well(e)Cnm lcted;q�K 4e0 I fl• ft.
5a. ell Location: /C n. 30� eo$WATl al C4 7 u:1 °r-clscu)t 1
--- . O 35D t' eoi-hei�lt^�P LA
pt.t.�� ;t-s t 14
pacithYtOwnerNtanme r 'n TaeilitylDN(ifapplicnblc)
lX (1�11
� R,
�vstcl'l Address,Lily. 1' ft.
and Zip .
k�LJ.,I 1. 21.);;t3MAitKS
Parcel identification No.(PIN)
Sb.i.atitude Rtid Longitude in degrees/minutes/seconds or decimal degrees:
(if1`11 field one lot/long iq sufyleient) J A N V
2 C rflRr on:
�r•�a
N 4 . 7 t
.»W !7 n.� Ilno;Frl4sn f'rr.^;���`si-�,r:i-Z�
6,is(are)the well(s)• t Si gmt o Certiffed Well Cnntmctnr j. eR
. Permanent or OTemporary
Jij,signing rh/c form.1 borAr crrAfy that rite ineli(s)a'as(were)mmirncled In aceardtnrrrr
7-is this a repniy 10 an existing well: 13Yes or j No Wiih 139 N4itCWC.0100 or 1sA NCAC 02C!0200 Well Cnnmrrnrtian Stanaordm and iliat a
1frhlSlSarepair•f/ion14nmtrltrollconrtnrrllnnfrl/ormattnnand crl�lntntbannnrrcnfihc cap-gr1h/mrrcordhashernprmidedlafix,11VIlntttrra:
rrq,nir ran/rr MII renrnr/s cecllnn n!'aa the hack nflhisjarin.
23.Site diagram or nddifinual well details:
&Number ofweliq constructed: — a"(5 f+ r `T YOR may use the back of this page to provide additional well site details or well
Frrr mnhl lc, �b construction details. YOU may also attach additional pages if necessary.
P l>lecttnn a non-rvntersrrpply weAS ONtYW/h the some conornerieft.)'On ran
srrhmit onejnrn,.
SUBMiTCAL INSTUCTiONS
?.Total well depth horns land surface: 24a.for Ali Wells: Submit this form'within 30 days of completion of welt
For n 11"I*"'ell,I/.vt all rhtuha 1/'d(f)errnr&Xon,ple-30209•and 2(n)n 100n
construction to(ltc following:
11)'StRtie water level below top of casing:
Ir,rter level iTahrnecnsing;rrrc"+" (tt.) DIViSionof Water QnaiftY,informationProcessingUnit,
1617 Mail Service Center,Raleigh,NC 27699-1617
t I.Borehole diameter:
(1°') 24b. or lnjectiLrn Wells: in addition toseiiding the form to the address in 24a
12.Well construction method: above, also submit n copy 0f this form VAtllin 30 days of completion of well
("c'auger,rotary,cable,ditect push,etc.) construction to die following: j
FOR WATER St1pPI.Y WIWLLS ONLY: Division of Water Quality,Underground injection Control Program,
1636 Mail Service Center,italeigb,NC 270M636
t3a.Ytetd(gpm) Method of test: 24e.For WRter Cp_anly&faiecti /ells'
20.E In andiron to sending lire form to
131).Disinfection type: rite addrem(m)above,also submit one copy of this form within 30 day5 of
Amount.- Completion of well comfuelion to the coun i health department of die county
wham constructed:
Frntn Ctgr_1 -
North Cnniti0a Department of F.nvim Gv ntn and Natural Resootscs•Division of Water Quality
Revisedjan.2013
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