GW1--06196_Well Construction - GW1_20230922

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WELL CONSTRUCTION RECORD For Internal Use ONLY: 1
This form canoe used for single or multiple wells
1.Well Contractor information: f. '
' Rex Meadows 14.WATER,TANES
FROM TO- DESCRIPTION
Well Contractor Name, . ft. ft. I .
2113-A fL ft.
NC Well Conaactor Certification Number 15.OUTER CASING(for multi-eased welts)OR LINER(ifs llenble)
FROM TO DIAMETER • THICKNESS MATERIAL
Clearwater Well.Drilling Inc. 1, IL 1`4 it. rid, in. ce'
Company Name 16.INNER CASING OR TUBING(geothermal c(osed-coop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. 1 in.
List all applicable well construction permits(i.e.'Counry,State.Variance.etc.)
3.Well Use(check well use) I7.SCREEN r -
Water Supply Well: PROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
)(Agricultural--V't ran �L.11 OMunicipal/Pub6o ft. in.
°Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft. ft' in.
❑lndustrial/Commercial °Residential Water Supply(Shored) -1&"GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&•AMOUNT
OUrigation ft. O MVO tt. 1.
tC7J�� 3�!
Non-Water Supply Well:
°Monitoring °Recovery I
Injection Well: rt. ft. I,
°Aquifer Recharge °Groundwater Remediation 19.SANINGRAVEL PACK Of applicable)
FROM TO MATERIAL , EMPLACEMENT METHOD
°Aquifer Storage and Recovery (Salinity Barrier n ft.
°Aquifer Test OStolmwater Drainage
°Experimental Technology °Subsidence Control
20.DRILLING LOG(attach additional sheets if etessary)
°Geothermal(Closed Loop) °Tracer FROM TO DESCRIPTION(color.hardness,soli/rock type,Rain also.etc.)
OGeothermal(Heating/Cool{mng Return)
r1 °Other(explain under#21 Remarks) I ft. 11 k1' ft. $OJ .� 16-
4.Date Well(s)Completed: l-1 1 -a3Well 1D# I,A ow I RIL ran,y_
1Q141'� CpIA�`t e
5a,Welt Location: LOVD 1 DS D. y
ri Iynksah ft. iI; I
.,r :it le F. =_
Facility/Owner Name Facility 1 (if applicable) fLa. .p..., „.,
Unt i l th CS i CW R . 110 ► ft. ft. p
l ' SEP 2 2 Z023
Physical Address,City,and ip M^ d d
v 21.REMARKS I t
County Parcel identification No.(PiN) I;
r,
Sb.Latitude and Longitude in degreeslminutes/seconds or decimal degrees: !,
(if well field.one lat/long is sufficient) Certifi tioD: i
r� r I.
3o" Ii I -1d N � ISd3 W 1-a.- a3
S• are of Certified Well Contractor +: Date
6.Is(are)the well(s):'l ermasent or °Temporary By signing this fours.I hereby cent&(&that the nell(s.ens(Mere)constructed in accordance
with ISA NCAC O2C.0i00 or ISA NCAG02,C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: °Yes or O copy ofthis record has been provided to the well onnrcrcr.
if this is o repair.fill out known nellconstnrction information d lain the nature of the I
repair under#21 remarks section or on the back of thisform. 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 infection a man-water supply wells ONLY with the same construction you can
submit one form. SUBMITTALINSTUCTIONS II, '
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9.Total well depth below land surface: 105 . (rt.) 24a. For All Wells; Submit this{form wi in 30 days of completion of well
For multiple wells list all depths ifdrfl-erent(example-3@200'and 20:100) construction to the following:
10.Static water level below top of casing: (.0 D (fk) Division of Water Quality,Info tion Processing Unit,
If water level is above casing,use"4-" 1617 Mail Service Center,Rat gh,NC 27699-1617
11.Borehole diameter: \Q`'I (in.) 24b.For Infection Wells: In addition to se 'ng the form to the address in 24a
above,also submit a copy of this form wi 30 days of completion of well
12.Well construction method: l U (k1(4 construction to the following:
(i.e.auger,rotary,cable.direct push,etc.) 11
Division of Water Quality,Undeigronn Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Ral igh,NC 27699-1636
13a.Yield(gpm) ,V Method of teal: 24c.For Water Sumthr&Iniectio t Wells: addition to sending the form to
___234_______ the address(es) above, also submie one cop of this form within 30 days of •
13b.Disinfection type[ Amount: completion of well construction to the coun health department of the county
where constructed.
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised]an.2013