GW1--06041_Well Construction - GW1_20230920

WELL CONSTRUCTION RECORD For Internal Use ONLY: •
This form can be used for single or Inuitp1e wells
1.Well Contractor Information:
Rex Meadows 14 WATER ZONES _ - I
FROM TO DESCRIPTION
Well Contractor Name R. ft
2113-A f. ft. 1
NC Wall Contractor Certification N r 15.OUTER CASING(for muld-cusedwelb)OR LINER Ofap &able)
FROM ' To -DIAMETER THICKNESS MATERIAL
'Clearwater Well Drilli g Inc. I a- 1 l Li ft- 1211$;in, INC
Company Name 16.INNER CASINGOR TUBING( othermalchased-loop)
rJ 2 „ ©�e�^- FROM DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: (1✓ ft ft. !in
List all applicable well construction per its(Le.County,State,Variance,etc.)
ft. It in.
3.Well Use(check well use): 17.SCRE1 (
•
Water Supply Well: Hum To DIAMETER SLOTSIZE THICKNESS MATERIAL
❑ cultural ft it In.
°Municipal/Public,
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft ft. la
OIndustrial/Cominercial ()Residential Water Supply(shared) 1&CROUT
FROM TO MATERIAL EMPLACEMENT METHOD do AMOUNT
°Irrigation ft' ft. YV�y,�{ _
Non-Water Supply Well: 9D &t I t(,r 1) �� �
❑Monitoring °Recovery ft' ft.Injection Well: ' • ft. : ft
°Aquifer Recharge ❑Groundwater Remediatlon 19.SAND/GRAVEL PACK(if applicable)
wfer Storage and RecoveryFROM TO I MATERIAL' EMPLACEMENT METHOD
O
Aq g °Salinity Barrier ft ft
❑Aquifer Test 'DStomtwater Drainage •
❑ExperimentalTechnology °Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
°Geothermal(Closed Loop) °Tracer
FROM .. TO DESCRIPTION(calory bardness,soWrecktype,grain sbs eta)
❑Geothermal(Heating/Cooling Return)2 °Other(explain under#21 Remarks) 1 ft- I t ft. aln a 4-- CMY t
4.Date Wel( 'ompleted:• U -��/ Well ID# 4, 0 R f tbDC
Sa.Well LocatroD. jl cc U ')ft l cnae.A -k-cirle, I t• 5b Ft it. ''U.
. o�5 ft (� plj ►t,(I
ict
Facility/Owner Name ` Facility lD>►(if applicable) 1. ,---,.„--n- e,,
f. i. _P ical Address,City,anddZ Zip
p 21.RF.MARKR SEP r c 2020
County Parcel Identification No.(PIN) Infn;s7 3;i5sn Pr^rce7. 4, lit)
Sb.Latitude and Longitude in de es/minutes/seconds or decimal degrees: 22. :lion:
(if well,field,one Iat/long is sufficient)
•
3St 14 5E3 N ?9 3to ' 5' w .A , : ,13-( 3
Signs , of ed Well Contractor Date
6.Is(are)the well(s): I Permanen or °Temporary `
By signing this form,1 hereby certify that the wells)nue(acre)constructed in accordance
with ISA NCAC 02C.0100 or ISA NC IC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: °Yes or 'io copy'Phis record has been provided to the Well ouster.
If this is a repair,fill out known well construction information and explain the nature oft/te
repair under#2i 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 provide additional 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 suppl wells ONLY with the same construction.you can
submit one form. C SUBMITTAL INSTUCTIONS '
9.Total well depth below land surface: COD ) (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dip (eramp►e.3®2000'anndd 2@l00) construction to the following:
10.Static water level below top of asing: S.
v (ft.) Division of Water Quality,Information Processing Unit,
If water level is above easing,use"+1 - 1617 Mail Service Cent er,Raleigh,NC 27699-1617
II.Borehole diameter: I (in.) 24b.For Infection Wells: In additions to sending the form to the address in 24a
lr1� of_L i above,also submit a copy of this form within 30 days of completion of well
12.Well construction method: 9 V l W construction to the following:
(Le.auger,rotary,cable,direct push,etc.) -
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS Y: 1636 Mail Service Center,Raleigh,NC 27699-1636
132.Yield(gpm)..___7
Method of test: 1q 24c.For Water Supply&Injection Wells: In addition to sending-the form to
the address(es)above,also submit one copy of this form within 30 days of
136.Disinfection type: Amount: completion of well construction to the,county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised)an.2013