GW1-2023-01090_Well Construction - GW1_20230126

�1EI-L CONSTRUCTION RECORD � �
This Corm eon 6c".wn Poratagtc or malilple wells For internal Usa ONLY:
i•Well Contractor Information:
Rex Meadows 14.WA7 ER ZON&S
Well Cantracior Name mom 1 D DUCRIMON
1I. ft.
2113-A
NC Well Cantmctor Certification Number
tS.OUMRCASING rrnn dwelt OR LINER st b[C
Clearwater Well Drilling inc. FROMTO DIAMETER Tlt[CKNgaq MATERIAL
fY. fr.
tompanytYame 16c1NMCA9INCORTUBING doltdlm
2.Well Construetlon Permit#: TO DiAME7i3R TNtCImns MATERIAL
lista11appHrahlrae/1cansnvction n• fi ip
perricl[r()e.Ctrrnt Stafe,I/arla11CA err.)
3.Wen Use(cheek wen use}; R• R
ES3ell , TO DIAMETERL
l7Munfcipal/Pubiicating(Cooling Supply) ❑Residential Water Supply(single)meceial OResidentialWaterSti 1 shared) ROi]PPY( TROM To MATRRUL BMPLAC6MBNTMB1MOD RrAMOnN7
Non-Water Supply Well;
❑Monitoring gRecovery rs• "'
injection Well: fl. tt.
CiAquifer Recharge QGroundwater Remediation 19.3AND/GItAVBL PACK fIfggjjg1Kkj
❑Aquifer Storage and Recovery gSalinity Barrier MON To I MATERIAL rEMPLACLMBNTMETnOD
ElAquiferTett_
OStotmwater Drainage
prKperimental TeclmgY ❑Subs)denccControl olo ft. 11,
1-J(3eothetmal(Closed loop) pTla 20.DRILLING LOG attach atldifleaal aIt Ir ,
FROM TO DLWMPT10N 2k sawnek io etc
gGeotherRal Heatin Cooliq Remm gOther( lain under$21 Remarks R• R• ��t1P,1—IVl� _
4.Date �11 {{ D# ft. R• (A;��d s Gz x�d
Well(s)Comp ed•"1" 1 L'2 ell 1
Well
.19 d S Tot
Sn. Location: �I
QxLurnar) C �.
Fflmhty/OwncrName ft y" t
l Taenity IDN(ifapplioabie) i—Cl i G f 1-7,
A.
Ph•meal add a. ft.
tt~ss,Cary,and 7.ip
21. KNIARKS 1 ;t
ti}r ,rn
cmrmy Pam]identification No.(P1N) Dti'SQi r�'�v
Sb.Latltade and Longitude In degrees/minnfes/sernnds or can
degrees:(ifwcll field•oue lat/longis sufficient) 21 Cer Callon:
N _�7OdG TI 2q �_ 2—O _7 Z
6,is(are)the wen(s); SI Dire Oified Weil Contraeinr re f
ertnanent or OTemporary
it..tlgning thde/am).1 homki.crilki,that the iWli(s)nos(nerr)enar►rrnferlla ncralYlanrr,
7.is this a repair to an existing well OVes or No Wth iSA NCAC 02C.01170 or 154 MC 02C A20D li'cl!Cacrfrrrcttar Staadardo card dint a
1frhEr is n, lr fr?rnu knnnv7 CanBtrtrcllntl lafarnlAlln»and r_t7>lrrin the nanrrenfthe `opt^jrhts record hav hertt prorl*d to fix,mrC/t alsver:
rrlrair mauler#21 reninrds seeltan orQltthe hack af/hisfarm.
23.Site diagram or additional well details:
_ �j You may use the back of this page to provide additional well site detaila or well
8.Number of wens constructed:
Fin'mrdl/plc In)ecr/nn at'narrtvrrterslrpply ur/le ONli'wuh!/re mme canyyrrutlnn,l�tn rate construction details. YOU may also attach ridditianal pages if necessary.
c ahmit nnejorm.
SUBMfTTAL INS MC nONS
F Total
ah We"city/W adepth ll rim ,.cOW afif
fnd Urfa 7nmplti 3dh20n nru12(a/00�
(ft,) 249. Tor All Wells: Submit this form within 30 days of completions of well
construction to tlmafollowtng:
11/.Static:water iv ca below top of casltmg: Division of Water nallty,information Processing Unit,
(/lrntrrl(.•rclicahm�c casltll„it9C"t' (ft.) Q
1617 Mail Service Center,Raleigh,NC 27699-1617
t 1-Borehole diameter:
(in.) 24b.For tniect it Wells: In addition to I ending the form to the address in 24a
12.Well construction method: above. plan,submit tt copy of this form within 30 days of completion of well
(i•c•auger,mtnry,cable,direct push,etc.) construction to die following; II�
EVIeld
1PPI.V WPt.LS ONLY: division of Water Quality,Undergrom1d infection Contras Program,
f636 Mail Service Center,]taleigh,NC 27699-1636
Method oftesf: 24c.Tor Water Sunnly&in(ectin�eIIV In addition tosending the form to
type; die address(cs)above,also submit one copy of this foci within 30 days of
Amount. complexion of well construction to the coin i health department of the county
where constricted.
P03 in COY-1
Nnnh Cnmlinn Depnrtment of Fawimnmcnt and Naluml Resotnres•Divislonof Wafer Quality Revised Jan.10 13