GW1-2023-01099_Well Construction - GW1_20230126

WELL CONSTRUCTION RECORD
Thil form rno be unca forsing[e nr mullipiC WClls li
ror imcmal Ilse ONLY:
1,Well Contractor Information:
Rex Meadows
14:WATER ZE)Nn I i
Wotl Cnmtactor Name FROM TO DESCRIPTION
2113-q ft' ft
NC Well Gonttaetnr Certification Number ft, ft.
Clearwater Well Drilling Inc. 1S-OUTER CASING for mu dwells OR L[NEIt a Hauble
PROM TO DIAMETER I TRICICNBS. MATERIA
Company Name ft' ft. I, In. L
ip l� I6:INNfiR CA91NC OR TUIIING thermal crated-lao
2.Well CoostntetlnR Permit#: Y�/ Cn 3 GROM TO
J.ian/f�tpJicahJrumJ/eons]nrctionpermltc(<e(.nunry.Slale.T�arlancr.etc/ DIAMETER THICKNESS htp=gy�L
H. ft In.
3.'yell Use(check well use): ft. R, In.
Water SuPP1Y Well: 17 SCREEN
OAgrieulmral ]PROM TO DIAMETER SLOTS12E
CMunicipai/Public it. ft. in, THICKNESS MATERIAL
)(Geothemml(HcaNng/Cooling Supply) 0 PCs identied Water Supp ly(smig e) ft• ft, in.
❑lndustriaUCommercial DResidentiel Water S» 1
❑Irri Lion Supply(shored) ta•GROUT
FROM TO MATERIAL EMPLACEMENT rytE
Non-Water Supply 1Ve11: (t. ff, THOD&AMOUNT
❑Monitoring
Injection Well: ClRecovery te. ft.
❑Aquifer Recharge ft• ft.
C1Aquifer Storage and Recove Groundwater Remediation 19.SANDJGRAVEL PACK a ]]cable
tIr gAquifer'fest DSalinity Barrier m ft.-mom To MATERIAL EMPLACEMENT METHOD
ft.
DStormwater Drainage
❑IixperimentalTecltnoiogy pSubsidenceControl ft' ry•
!7(lcotitermal(Closed Loop) OTracer 21 DRILLING LOU attach additional shear i[neea
❑Gcorhetmal Heatin COolin Return) OOthcr(e lain under#21 Remarks FROat ft. TO
t- iL DESCRIPTION rotor n.'a",� nick nln a cte.
4,Date Wells)Completed �l-22 H- i J ft.
r'�'Q{-
Well ID#
Sa-Well Location: ft. 7t.
4 it. ft.
facility/Owner Name- it: ft.
�racility ID#(ifapplieablc)
Ph •ical Addrees,City,and zip' ft. '
t ft.
L
21.RfiMA,RKS
Cmmty
Pmcal identiftcntion Na(P1N) rMIA11JQJ3rJC-
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees;
(if well field,one laillong is suthcient)
5b �i 2 . cr Callon:
N � 3 E i OQ W `�
6,is(are)the wells• ~ O L�
O' ermanent or SiBnntnleOfCenifiedWellConttacinr[]Temporary Date
121.signing l l fonn,02C'7 herehv cci7ff+,,that nc0 a eR(•v)u•nr(nrir).»aclnrcicd in arenrd Mire,
7.1s this a repair to an existing well' ❑yps or afih 1SA NCAC t71C.0700 a•LSA NCAC ll�C A?OD ife)1 Construction Standardc and that a
(f lf' iT n rznalr,fill nor l;•nm,D)-f constnicllan lrfrn•utallnn alr�N lain the COP.',of•tliiv rer-ni-flims here p "A k to the urll au7rel:
re�rnir under tF21 remar6s sedinr,nrnn the back oflhis fnrin. / nantreafrhe
�����- 23.Site diagram back
additional well detatis:
P Number of wells constructed: YOU may use the back Of this page to provide additional well site details or Well
Fhi nfnnpJc in/ectlnn or non-tvatersu 1 Construction details. You may also attach additional pages if necessary.
.vahaiit nncfnnn. PPY wells ONLY m!!h the soma tons�rndinn-)orr rnn
9.Total well depth beloty land surface; SUBMITTAL INSTUCTiONS
For nrn/nliJr++•cl/,v/1.T1 all rlepl/av/fdi vrent(ernniplr-3�n]?00•nerd 2Qih0� (ft) 24a. For All Welts; Submit this fomt within 30 days of completion of wel l
I D.Statle water level below topof construction m the following:
Flit"'lrrel it ahmw eavbnl;.nse'•+,, eaSmgt
(f>) Division of Water Quality,info
lrmutloit Processing Unit;
1 i•Borehole diameter: 1617 Mail Service Center,Raleigh,NC 27699-1617
Cu') 24b.For In action Walla; In
12,Well construction method:
in 24a
above, also submit at copy Of this
h sttform withiiion to n 30hdays of co»lpletioaddress
of Well
(r•c.auger,rotary cable,direct push,etc,) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Of
13n.Yield(gpm)
Method of test; 24e FOr Water 5u 1 &Injection Wells: lit addition to sending the form to
13b.Disinfection r the address(c4) nhove, also submit one co
�C0 Amount: completion of well construction to the county icalth department of thpy:4 this form within 30 e countywhere constructed.
Form CW_r .
North Camlhta Department of Envimninent and Nntuml Resources•Division of Water Quality
Revisedlnn.2013
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