GW1-2023-01091_Well Construction - GW1_20230126

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WELL CONSTRUCTION RECORD
This firm rnn be used faraingle or multiple wells For bulemal 1Jso ONLY:
L Wen Contractor Information.
Rex Meadows 14,WATER ZONES ;
FROM TO DESCRIPTION
wellCotntactorNalnC t1, ft, l
2113-A
NL•Wall Contractor Certification Number 1S.Otn"CASi O rmaabpredweas•ORLtMR a
Clearwafer Well Drilling Inc. FROM It ft, 7D(913 ft. ° �rtaR la TAtcicNEss MATERIAL
Company Name i&INNER CA81NG OR TUBING elotetsloa
2.Well Construction Permit#: FROM TO DIAMETER 7HtCKN633 MA79ML
I.ict nllal,plimhlr taeJl emishutxlon pemrils(he.Calm&.S141e,Yarlmrrr. n' ft in.
3.Well Use(check well use): ft. fl, Ip. ,
rus
Well: 17 scRBEN
FROM � nrAatla'1'eR aroT� Turctays�sv tMAT6RrpL
am micipai/public R• tt. In.
Heating/Cooling Supply) OResidential Water Supply(single) ft. rr. In.
mmetoial Olkesidential Water Supply(shared) I&.CMGUT
FROM To, MA RIAL r nMPLACEMBNTNlETIIOD&gMOttNT
Non-water supply Well: ft. 7o !1.
[)Monitoring OReeoverY
Injection Well:
ElAquifer Recharge 13Gmundwater Remediation 19,tiIANWGRAVBL PACK f061ftwill
0 Aquifer Storage and Recovery LlSalinityBarrier FROM I MATERIAL. EMPLncBMENTMBTnon
IJAquifer'fest U, fa
OStotmwater Drainage (6
OExperimental Technology 13SubMdenceControl I it.
4Geothetmal(Closed Loop) o'iyace 210LDRILLINGI.OG ItetieobnddlNtultlaheattit
FROM TO DEBCBiMON celor huLamicilmock M Into 1174 arc.
I7Gcothermal Hearin Cooiia Return 130therfeRlainunder#21 Remarks n• a• /�jG
[ ,Q, ft. D B• c I &l
a,Date Well(s)Completed; IMF ZZWep ID# C
tr. ir.
Well Location: 1
Uj { fr. O(X R
pacility/t7wncrlVs{rm�e (� Facility ID#(itt arp(plicnble)
S3 I' 1 11 1 t P��.� rt. f+. i `��, E.m r �s k�...,/
.,
Ph real Adtlrese,City,and Zip
k27-f
1'r,t:,z%miill Ur� l
Pm>tsi rdentiUcarioa No•(p1N)Latitude and Longitude in degrees/minutes/seconds or decimal degrees(ifwcll field,one laUlongissufl'rcient) iOn: i, f
Sig fCenifred Well Coalruclar irate
ti,Is(are)the weil(s); Permanent or OTemporary
11Y signing this form,1 hereAr rrrlljV that the"ill)was(were)e:ortsina7ed io 7rLyjrda,)ry
7.Is this a rcpalr to an existing well Oyes or No 1111h 1JA W AC 07.C.0100 ar 15A NCACO2C..020017e11 Cnrccenr,don Standarde and that a
ifthic is a rcnair,fill alit damryl tt ell c'nnserrrctlnn lriiarynalln»and emJniir thenrmnc njihc COp1 rrfthdc rrcyrrd heir hCrr1 Ju rrvldrd to Litt tmli nuttt r
repair undr-r 021 re'""kv sec7inn oron the hack afihis forin.
23.Site diagram or nddi6noai well detatlq:
8.Number of wells constructed: You may use the back of this page to provide additional well site details or well
F"mmrdp:lc,r' CODS1DIct1OO details. You may also attach additional pages if necessary.
{ I1ecllnnOrlrnll-,vn►erarrpplywellsONLPtrlthAmsomecanslrnMian,foneml cuhn,il nor.jnnn. SUBMrTTAL INSTUCTliONS
Total well depth below Land surface; VG OS (rk) 24a.For All Wells; Submit this form(within 30 days of completion of well
Fnr m)11111 c u'c//,c"stall dlptlxc i{dicrent(crumple-3tt@2nn0O 2@10011 construction to the following:
10.Static water lever below top ofeasing; �C
1f uytlro
(ft.) Division of Water Quality,Information procening Unit;
lire!le ohm a eip'!nl,ace"+" ` 1617 Mail Service.Center,Raleigh,NC 27699-1617
t I.Borehole diameter: '� �
Cam) 24b.For Inteetipn Wells: Ito Addition toIsepding the form to the addims in 24a
�c�y �n above, also submit rt copy of 1hiS form,within 30 dayil of completion of well
12.Well construction method-_ \ l n 0 �_l
(i.r.auger,m Th.etc
tnry,cable,direct constnrction to the following:
er•c )
I' ,
FAR WATER SI1PPLylW1LLLS ONLY; E] Division of Water Quality,underground injection Control program,
/ 1636 Mail Service Center,ldalelgb,NC 27699-1636
13a.Vield(qpm)_ Z
Method of test: 24c For Water Souoiv�c injection Well in addition to sending the form to
the addregq(eq) obovc,also submit one copycopy of this font Ohio 30 days of
Hlslnfectlon type cornpltdifin Of WC11 Construction to the county
Amount; health'department of the county
whorc collstnicted.
F01111OW-1 - - J�
North Clnrl Deportment of F.avimnencnt and Natural Ramulvcs-Divisionof WolcrQuality
• I Revisedlnn-2013
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