GW1--07305_Well Construction - GW1_20231109

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: •
Rex Meadows 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2113-A ft. ft. I I
NC Well Contractor Certification Number 15.OUTER CASING(for mu1H-cued wells)OR LINER(If ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. i ft. 40 ft. lQ itc4 In. I Vie _
Company Name 16.IN NER CASING OR TUBING(geothermal eloeed400p)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit it: ft. ft. , in.
List all applicable well construction permits(i.e.County.State,Variance.etc.) ft. ft. in.
3.Well Use(check well use): 17.SCE(EEN I
Water Supply Well: 'FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUpublic ft. In.
°Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. It. In.
❑lndustrial/Commeteial ❑Residential Water Supply(shared) I8.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 1 ft. a("� ft. /i/fin tt t - dAf�,c i pN
Non-Water Supply Well: c.�i✓ lXs3 I� ` 1I 1 1 V s�
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Of applicable)
FROM TO MATERIAL I EMPLACEMENT METHOD
RAquifer Storage and Recovery ❑Salinity Barrier ft. ft. I I
❑Aquifer Test ❑StormwaterDrainage
ft. ft.
O&xperimentai Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets If a essary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DES�CRIrPTION(color.N.ranestysellMuk type,grate she,etc.)
°Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) l I ft• ft• c_�.C.1 ct 4,6k V'-\
4.Date Well(s)Completed n_'^��t 01 Well ID>1 \ rQ �'iZi� 3 Q ��r("��t
58. a Location: I I itl�v ii.w�t� J�"" �11 ft, p tf -ft. 6 /� ys ' V . _
it.
ft.
Facility/Owner Name Facility iOP(if applicable)
ih ft. NOV I) '� 111Z
IAlhi-ie_ -1-l ciw, _�' cover AU e. ft. ft. Its,.�. _ ,,1 ;,,..,,: -3 ;
Pit{/y�rjsicat�A�a�ar�c//s,�'Ciryi,andZiip�� t �G 21.REMARICS 1
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certi cation:
(if well field,one latilong is sufficient) t �
(3S 44 lOtp N Sa . 1 4-1 a W , _ B.aa-a3
Signature of Certified Well Contractor Date
6.Is(are)the well(s): !(Permanent or ❑Temporary By signing this form.I hereby certj that the nrll(s)ass(were)constructed in accordance
with ISA NCAC 02C.0100 or iSA NCAC MC.0200 Yell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or O copy[phis record has been provided to the well owner
If this is a repair.Jill out known well construction Information an a lain the nature of the
repair under t121 remarls section or an the back ofthisform. 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 nrePceary.
For multiple injection or non-water supply wells ONLY with the same construction,you can ;, I
submit one form. �^ SUBMITTAL INSfUCTIONS , JI
9.Total well depth below land surface: `/1 (It.) 24a. For All Wells: Submit this form with 30 days of completion of well
For multiple wells list all depths if different(erample-3@200'and 2@l00) construction to the following:
10.Static water level below top of casing: 10 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+"" t r 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. l 0 I 0 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: ��/� �/ above,also submit a copy of this limn with 30 days of completion of well
(J� construction to the following: 1
(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 27699-1636
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13a.Yield(gpm) CD Method of test of 24e.For Water Supply&Injection Wells: hi addition to sending the form to
the address(es) above,also submit onei copy of this form within 30 days of
13b.Disinfection type: Amount completion of well construction to the count}health department of the county
where constructed. I
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality�t Revised Jan.2013
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