GW1--04882_Well Construction - GW1_20230728

yr7'uLl,a.vlvax/tUt-IIV1't 1[11(.01(1) Forinlernal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Rex Meadows 14.WATER ZONES
FROM TO DESCRIPTION I
Well Contractor Name ft. ft. i
2113-A D. ft. i I _
NC Well ConbactorCertification Number IS.OUTER CASING(for multi-cased wells)OR LINER(If ap ncable)
Clearwater Well Drilling Inc. FROM ft. TO$ rt. I
DIAMETERill in. I IICKN�s PVC)
Company Name 16.INNER CASING OR TUBING(geothermal]dosed-loop) "
FROM TO DIAMETER THICKNESS MATERIAL
2:Well Construction Permit#: ft. ft. In.
List all applicable well cousinu:tion permits(i.e.County.Stale.Variance,etc.)
ft. R. in.
3.Well Use(check well use): 17 SCREEN Ii
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OA cultural ft. ft. in.
6`ri OMunicipalPublic
❑Geothermal(Heating/Cooling Supply) yjResidential Water Supply(single) in'
Dlndustriall m Comercial ,❑`Residential Water Supply(shared) 18,OM GROUT
FR TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
❑on-Wale 'gation
71) C t I I �
Non Water Supply Well:
OMonitoring ORecove ft. ft
Injection Well: ry
R• ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ['Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stoimwater Drainage
❑Experimental Technology ❑Subsidence Control R
OGeothermal(Closed Loop) pTra 20.DRILLING LOG(attach additional sheets iflneccasary)
FROM TO DES O elm;hue jams.sgIVroek ape.grain sire.etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft• ft y
r ,, r " I
4.Date Well(s)Completed:LO l-5_-2 3 Well ID// I 0 f. L :
5a.Well Location: Sc) � 1- (u 4 Oft- y.l ` I1C
4.11. ft. ft. C /) /A A e
k 1 i (i.r\,) P ober+ EI4larme\v � 5 RJ
It. ft.
Facility/Owner Name Facility!DI/(if applicable) I a�''t"A
H. (t. /°ot®i r:
I I t)cnc1 Cio sinq Marshall :, - e� R
� r rt. ft. I't �'—� --
Physical Address,City,and Zip N C 21.REMARKS i 11 J L �� ,-, `il 13
MOOrliSOn J
Ufa
County Parcel Identification No.(PIN) -, ill
ifOGW-Vralai,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.C cation:
(if well Held,oe lat/long is sufficient)
i ` 11 '��11 (9q(P N �at a tg- 1 w (9I -d3
Si lure of Certified Well Contractor Date
6.Is(are)the well(s):XPermanent or OTemporary By s ng this form.I hereby certify that the well(s)mu(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.01001)Yell Cunstnrction Standards and That a
7.Is this a repair to an existing well: ❑Yes or a copy of this record has been provided to due well owner.
If this is a repair,fill out known well construction information a es lain the nature of the
repair under 01l remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provid additional well site details or well
8.Number of wells constructed: construction details. You may also attach add'Tonal pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit wicket. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: t4-35 (it) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdTerent(eromple-3@200'and 2(1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing, C�use 1- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: l.Q ' (in.) 24b.For Injection Wells: In addition to sendling the form to the address in 24a
12.Well construction method:
�� above, also submit a copy of this form with n 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Undergroun Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
1
13a.Yield(gpm) I 0 Method of test: 24c For Water Supply&Injection Welts: addition to sending the form to
� Xn the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type. L
\Bone, Amount: (v)lnl ,Q completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina De
partment of Environment and Natural Resources—Division of Waver Quality Revised Jan.Z013

W11 Driller S.1LiiiUt Cordikaition
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