GW1-2023-01097_Well Construction - GW1_20230126

WELL CONSTRUCTION RECORD
this roan rnn be atcd Wrainglc or multiple wells Ter internal isle ONLY:
1.Well Contractor Information:
Rex Meadows K WATER ZONIL4
Well C:nntfaclor Name TROM TO M8CRIPTION
2113-A n ft.
ft. R. `
ldL Well Cannactoreertificntton ldumticr
IS.OUTER CASING round teed ws1L OR LitVER ti We
Clearwater Well Drilling Inc. FRaM To DIAMETeR1 I Tnit`KNBttg MA?tiRtAL
Cnmpsny Name ft' R• t t In: d
ijc�y f��c•1��'9 1fk1NNERCA81NGaRTURING thnrmaleteted•Ioo V
2.Well Construction permit 11.. ..2�/�� VO��� To DtAMRT6R 7HICKN[t.44 MATewnL
ict rill gpJ,Hcahlr hell comIn zdan ry n i4
prt.11Gt r.G Crum SWt.,1rarlmtcG eh'.J
3.Weil ijse(check well use): R• (..
Water Supply Weil; 11.acm N
GROM TO DUMET6R SLOT 912E TRICFCNL+49 MATEpIA4
[]Agricultural QMun(eipal/pub6c ft, R. t4
CtGcothermal(Heating/Cooling (t, R, in.
E�PPh') asidentiel Water Supply{single)
❑lndustr(eUCom►nerciel OResidential Water Supply(shared) 1R'GROUT
i Irri Lion FROM TO MATERIAL 9a1PLAC8 METHOD&AMOUNT
Non.Water Supply well: f► !L I
[Monitoring ORecovery
Injection Welt:
LlAquifer Recharge ❑Groundwater Remediation 19.SAt11D1t�EtAYBL PACK f illuble
Ll Aquifer Storage and Recovery Molinity Bonier FROM TO MATERIAL EMPLACEMENTMRTHOD
LlAquifer7est ft. R.
OSUmilwater Drainage
CrxP manta!Technology R. R•
gY 17Subsidence Control
❑Geothermal(Closed loop) ClTraccr FRO1RiLLWC I.00 addlttaad r task
FROM TO DF_4t.•ttiP710N mar to rat4teook In elc.
00colhesmal lieatin Conlin ri— 00ther lWaunder#21 Remarks n• R. `f
a.Date Wells)Completed / 2Wet11D4
}Se-.Well i ocation; Vaq WAS 1,�•GL ft. 1 n• (►JC
AA
Facility/AwnerNamc
Facility IDq 01'applienble)
in
V 4-
Phy teal Address,City.and zip n• rt.
21. itMARKS
County Prac-wQh.%j llrtrl
FAtecl identification llo.{Pill) 1 Y—
Sb.i.adtude and L0491tude in deVecs/minntes/seconds or decimal degrees:
(ifwcli field,one latAongh sugiic(elu) 2 ,C tifj flan:
Qm i a `- N 000; �1 n:.2.,O W _ _ ZZ
fi,is(arc)the wells; Il a Sigtmhire o citified Well Conhactnr -7' rite
{) rntaRent or C3Temporary
R!'visaing th/,t form.7 heivAr eer»fv that fire xr/l(sj nm•(Were),»nsti7ved to arLVj loin
9,is this»repair to an existing wen: 17Yea or Vo µdth ISA WYCWC.0100 or 154 NCAC 02C.#200!sell Cmtttr"di.µ St.nrlot dt and that a
if dris �ymir,fill mn knnnhi µm1l cnnstnrdinn JtJornposln»a,�d�tlrtin thenanne oflhe ���rhsy MIX»rl bra her»pnn'ldrd to the neAiitrner.
nrlrnir a.dc'r#21 raniarlx sectl.,01-01,the backs this nl•1n.
f .� 23.Site diagram or additional well details.-
S.Number of walla constructed; You may use the back of this page to provide additional well site derails or well
Pm'mall/pleblicerlWl or.nn_ivnter.ngrplywNsONLYWIJ,the somec.ntrraetloAionemt C01115tTRWundetallS. You May ALSO attach additional pages(fmcessary
snhinit ancfnrm.
SUBMi'"AL INSTUCTiOIVS
9.Total well depth below land surface;
34S-
F"r Meltlple walk/itt all rhyrthe i/'dlr/ererrr(eramplo-3(r)200'mrd2(r - (ft) 242-l•ltr All Wells: Submit this foot within 30 days or completion of well
construction to the following:
11►.Static water i how top of eosins:
lcrrfirnhmle Divkion of Water Quaittp,Inr9rrllation �Prpng1 ppit,
1/nntrr caving
slngr,rise (ft.)
tt�(i I.Borehole diRmeter: 1617 Mail Service Center,RAlelgh,NC27699-1617
tJ •
(in) ?Ab.For Iniectisp We1is: In addition to standing the form to the address in 24a
12•Well construction method: above, also submit it copy of this form within 30 days of completion of well
G.a Auger,minry•,cable,direct push,etc•) -- construction to die following:
FOR WATER SUPPLY WULL4 ONLY; Division of Water Quality,underground'Injection Control Program,
1636 Mall Service Center,RRteigh,NC 27699-1636
I3a.Vtetd UIPm) Method of lest: 24c Par Water 5unnty&iniectton Weltg In addition to sending the ftntn to
13b Disinfection type; me addresses) ahove,also subinit one copy of this form within 30 days of
Amount: completion of well construction to the county health department of the county
where eolistructed.
FattnCtii.t �
Nndh Carolina Depnrtmeni of F.nvin,nineµi nod Nnhirnl Resources•Uivisinnof Water Quality
Reiiised)nn.2a13