GW1--06044_Well Construction - GW1_20230920

1
WELL CONSTRUCTION RECORD
This form can be used forsingle or multiple wells For Internal Use ONLY:
1.Well Contractor Information: 1
Rex Meadows 14.WATER ZONES i '
FROM TO DESCRIPTION
Well Contractor Name rt. ft.
2113-A f4 ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap liable)
FROM 70 DIAMETER THICKNESS I MATERIAL
Clearwater Well Drilling Inc. ( R• 9 S ft, 01 F in. IN
Company Name 16,INNER CASING OR TUBING(geothermal closed-loop)
FROM 70 DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. R. : in.
List all applicable well construction permits(i.e.County.State,Variance,etc.)
ft. ft. In.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: • FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public It. rt. In.
❑Geothermal(Heating/Cooling Supply) O[tesidential Water Supply(single) m R. Ia.
❑IndustriiaUConunercial ❑Residential Water Supply(shared) I&GROUT
FROM TO
MATERIAL EMPLACEMENT METHOD&AMOUNT
❑In-Wate 1 FL I,I`� ft. NUM-
EM 0 pf 11L ¶lli
Y�
Non-Water Supply Well: ` 90 `!!ai t tJi,V to
❑Monitoring ❑Recov R. ft.
Injection Well: mY ft. ft. I ' '
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(ifappllabte)
OAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD ,
ft. ft.
❑Aquifer Test OStormwater Drainage
It. R. I
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
OGeothernal(Closed Loop) ❑Tracer • FROM TO DESCRIPTION(color,,h rdness,salt/reek t pe gnIa she.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1 i'15 ft- n1)
n D- nAilli
ar' °�l'lll(/)•-
4.Date Wells)Completed -3 13 Wen ID# K ^ IR. rt. cl I
Well Location: 6t,,) ft.
CoOS it O
It^. arci Krei r Lrr �U IL ` Rt, I I
Facility/Owner Name A pilekk.Lk(,.n t Facility 1D (if applicable) ^-
1101 LoAl d.>lt Y SVUO 3LnOCi ft. ft: .., T'"_. . "'.
,_.., a
P ical Address,City,athi Bp (� g/
16J$�� r�+v 21.REMARxs FP L lM 23
County Parcel Identification No.(PIN) iftiV4rZr-'N:tF41 rt;-,;extig;g Jr'i
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: • G°r ,� `L`
(if well field,one ltat/long is sufficient) r Certifi tiara:
c5t 3li ass NSgMY311 W ...,,,,,------ -3- 23
Signs of rtified Well Contractor Date
6.Is(are)the well(s): 'ermanent or °Temporary
By signing this form,I hereby certify that the wells) tas(were)constructed in accordance
with ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 I ell Construction Standards and that a
7.Is this a repair to an existing well: [Wes or No copy(Phis retard has been provided to the Well owner
((this is a repair,fill out known well construction information and explain the nature of the
repair under#21 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 .dditional welt site details or well
8.Number of wells constructed: construction details. You may also attach additi'nal pages if necessary.
For multiple injection organ-water supply wells ONLY with the same construction,you can
submit oneform. n(�WOS— SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 6l (Ft) 24a. For All Wells: Submit this form withi 30 days of completion of well
For multiple wells list all depths if cbjferent(example-33CZ OD'and 2Q100') construction to the following: 1
10.Static water level below top of casing: U/0 (f,) Division of Water Quality;Info 'on Processing Unit, _
If water level is above casing.use"+" 1617 Mail Service Center,Ralei b,NC 27699-1617
U 1 l�g H.Borehole diameter: (in) 24b.For Infection Wells: In addition to sendi g the form to the address in 24a
above, also submit a copy of this form with' 30 days of completion of well
12.Well construction method: r i- -i construction to the following:
. (i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground ejection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Ralei b,NC 27699-1636
13a.Yield(gpm) 3 Method of test: 24e.For Water Supply&Infection Wells: In ddition to sending the form to
11 the address(es)above,also submit one copy f this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county ealth department of the county
where constructed.
Form GW- m
1 North Carolina Department of Environment and Natunl Resources—Division of Water QualdY Revised Jan.2013