GW1--06040_Well Construction - GW1_20230920

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Rex Meadows FROM TO DESCRIPTION
Well Contractor Name R. ft. 1
2113-A ft. It 1 1
NC Well Contractor Certification Number 15.OUTER CASING(for mutt(-casedwefs)OR LINER(if to ttcable)
FROM TO DIAMETER ' THICKNESS MATERIAL
Clearwater Well Drilling Inc. I` it. ft .i `n I PUS
Company Name 2 ��//�� ,( 16.1f4NERCASING ORTUB G(geothermal elosdd•loop)
201J CIO
[7 y' FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit If: ( 1 it, it. in.
List all applicable well construction permits(le.Comity.State.Variance,etc.) ft, ft. in.
3.Well Use(check well use): 17.SCREEN i
Water Supply Well: FROM H. TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
❑Agricultural CI Municipal/Public
❑Geothermal(Heating/Cooling Supply) stesidentiai Water Supply(single)
ft ft in.
°Industrial/Commercial ❑Residential Water Supply(shared) GROUT I
FROM TrO) MATERIAL ' y EMPLACEMENT METJIOD&AMOUNT
❑Irrigation / R. t�0 ft. Cone"11- 111/wl ig(^tfY/
Non-Water Supply Well: it. ft. I
❑Monitoring ❑Recovery I
Injection Well: • ft. '❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) I
FROM TO MATERIAL I I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier R• I
❑Aquifer Test ❑StormwaterDrainage ft. it.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if ne elsary)
❑Geothermal(Closed Loop) °Tracer FROM To DESCRIPTION(cater,hardness,sellirock type.cram size.eta)
❑Geothermal(Heating/Coolinng +�g Return) ❑Other(explain under#21 Remarks) /`
( it i S R. . /1( 4- (-
4.Date Well(s)Completed: 11 eU IDS I i� /71 /ff
)e
5a.Well Location: `77 IL Z&S it'
LtC4t ft. ft i —
IDN ifa applicable) Q 7.4 i ---)
FacilitylOwnerllame Facility ( ) ft. ft. `) c�, �i, <b�
a) Et"1C \ClU N 1 Cal. UAL ft ft. I_
ysical Address,City,and Zip 21.REMARKS 1 S 1_P ;'r ti 2023
be,
Parcel Identification No.(PIN) IIK i pr.rx::,l .,.,
County I ri'kevi Not'
Sb.Latitude and.Longitude in degrees/minutes/seconds or decimal degrees: 22.Celli :
(if well field,one latllong is sufficient) 7 R i 31 t tit^ ��
t � i 5ia N (_�+ W
Signal of - red Well Contractor Date
6.Is(are)the well(s):y�Permanent or ()Temporary By signing this form.1 hereby cert j that the well(s)nun(were)constructed in accordance
//''�� with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 'ell Constntction Standards and that a
7.Is this a repair to an existing well: ❑Yes or copy aphis record has been provided to the well mare.
If this is a repair,fill out known well consmtuion information lain the nature of the .Site diagram or additional well details:
repair undertt21 remarks section or on the back of this form. You may use the back of this page to provide•dditional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple Injection or non-water supply wells ONLY with the some construction,you can SUBMITTAL INSTUCf IONS
snlonii One form
9.Total well depth below laud surface: C7l a J (ft.) 24a. For All Wells: Submit this form with n 30 days of completion of well
For multiple wells list all depths it-different(example-3@t 200 and 2©1001 construction to the following. j
10.Static water level below top of casing: 4'0 (ft) Division of Water Quality,Inforitation Processing Unit,
If water level is above casing use
l"++" i 0 1617 Mail Service Center,Rat'gh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sew ing the form to the address in 24a
12.Well construction method: IV)1� above,also submit a copy of this form wi 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: r
1636 Mail Service Center,
ter,Rai lei,NC 27699-1636
24c.For Water Supply&Injection Wells: addition to sending the form to
13a.Yield(gm)
Method of test the address(es) above, also submit one copy{of this form within 30 days of
completion of well construction to the county health department of the county
13b.Disinfection type: Amount: where constructed.
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013