HomeMy WebLinkAboutGW1--00525_Well Construction - GW1_20240118 SC
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This limn mil he rsed for single o:multiple wells
1.Well Contractor Information: ,
14.WATER ZES ON I
Rex Meadows FROM TO DESCRIPTION I
Well Contractor Name R. ft. I - —�
2113-A ft. 1 ft. I I 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased=DO OR LLNEt1(If applicable)
'FROM I TO DIAMETER ..I THICS'tESS MATERIAL
Clearwater Weil Drilling Inc. ._.,_.._,_._-____.., _../ ft. in ft. �Q`I 3'in.j pve,
C yNan= u',-€vara :ill M 3V:in(geoih,^rntal closet-loop)
C...r_a FROM I TO 1 DIAMETER THICX.1ESS MATERIAL
2.Well Cimstrodiee Permit#: __ _ . ft m.
list all applicable well construction pernat.(i.e.County.Sate,Parlar.:e,e.le) - ft j • 1 u Z,,
a,Wen Ilse(citccu well use): i 'i 7,S:idrivie - _.-i _ j M- 1 - 1
j Water Sutittly i'ell: ,r ,- { a.
i ClAgticuit`tir<il ElMunicipab`Fubiic I 1 ; -r---------- {{
I i cicothentaii tHcwtiutc!_V&in &ri ..ly) X7.-•Lzeti ;Valet S'.pply(-siog_le i I --i ._ - .—_...._-.-�j{
I - _ r ._. l: .$.[:.•7. r-ri t i L tr:itF�it'_._•_!Jetztt__e2: _ -r .•le:... 'r,,,•-_::!•i '�:gm2 ;_^:t./_/��_ ,/�'/I.tT..rPS.`.I^-- t FSy�'./�y'�.�^E��ti E..S�•:..I':itC^::�:if:L_:T
I ikon-water S mpi-v Weii: i
.._,n . IL-- -'-'- - -- --•---- --' ----- ----• -------- -- - --
!i7Afn-;r ny; -?2F. s -^ -— t I i
f3Agttifer Recharge DCJratuitiivatcr Rt.-mediation I •ig.-S.lti i,IZ1'/3iL i'fli't CiiF> leak)-- - - --— `
tt r:il 1 rn t S.I.F:s:1 i. 3 IEbitt cllf.IS':5ttitttt=� _.j
t i?t:•tc ter 3iTly:er:u,:I Frt•.:br!. 11:14/•en,.tc. ,r as - 11.
-^ _ -._._—_ . 1
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•l�]::SfiCRilh'Ui it Technology
OS:ibsidenw Control ) �• �,F.. •• ���h�: ,: u �-t..� _...t i
r ,t. °((,'-, 9 :..�, 1R.t=:... It __ -::•i> _ - itai-: _ _ --i:::}� ::v�*
Lt jj
I_t• --`.4ttarf„ ,, i
_ .- i es
. .
� " _z Cu �T
e_ o_8Scsi(S;rzl:i:_�L:i�-all
-! .i..•:)„ t1670 T• I10 f I L ! i__
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q-leyiu. Sbakoh &_de._s_Dn i ________.
11. € 1
i•acilityi4_taner r=^t. Facility IGr Of ureter-Able) 1 E i f!_ t
Mar\iD _ , --: ( F: . : , �
Physical Address,City,mad lip 21.1ZEMARICS E 1
�G( fsDf _ ; ,JAM p. s t114
County / Farm!!dam tifiction No.(PIN) { , ar-.5*.601; ' kiri
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2 e 'ftca on• C)i`x Gin O G
(if well field,one Int/long is sufficient)
/\7 3 r1 n �t_--� ' 1l - Li-,3
Sigr.. enifed Well Contractor Otte
6.Is(are)the well(s): €'ersttnnent or OTemporary By signing this form.I hereby curt •that,the wells)t as(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC'02C.0200 II 4/Construction Standards and that a
copyOf:his record has been prarided to tic well owner.
7.15 this a repair to an existing well: uYza cr „o I
;(this is artpr-ir,fill can ini,cr t...,l .a i rntr,e:ain,r is jrrr.+a.ine and:�tiain the natrisr.sft, .
repair under#27 remark section or on the back of thisfortn. 23.Site diagram or additional well details:
You may use the back;of this page to provide a ,itional well site details or well
8.Number of wells constructed: Construction details. You-iii:ty also conch additi tat pages ifneceisaty.
Far multiple injection or non-water supply wells ONLY with tke sane caustrtctia:,you con st_R�i ici•':.•"q Lt�::s tom; '
at:br:;il one fiat, '}
4 Total wail depth below hind surface: t:;C 7 (IL) 24n.For MI Wells: Submit this'fann withi 30 days of completion of well
tall ! (example- construction to the following:For multiple wells fir depths i.ddJ-rent era _v
(..Y to:r",) si::. L Water'r tatlijy is ierr, Ma a rn:e [lg Unit,
ill.Static water tevei below tep.of casing: 1617 Mali Service Center,Ralci-h,NC 27fi i9-l617
La Ijxrrte!level is above casing,use'+" i l S.
inl t._. 24*',t or tn9cct sn 1's'a1tc: Li adtiiticn to sendi a the form to the address 24a
11.Borehole diameter; ci:•I
above_also submit a coin of tltisl form 'willi)i 30 days of completion of well
1Z,'W 11 bt i:SiTAs'.::On:.iiittsod: - --,,,` construction to the followings, t
(i.e_auger,rotary,cable,Direct push,ate.) •
Div;c(fa of Wafer Quylity,kiitt e g runrr E ftjeclien Control Fragrant,
1_—_.—_— -------•-•----, 103,5.nail .r c. . - Hale
t:?itk iv Al-sii;.SCi'3'.i..y' z.L.csNLl: 1 ''' t :'C.,i'
t -1 24r.Far °r Supply&milt tin.WAN: in:twits;n to sending die irx
1 13a.Yield(it-nr) 15 Aletbod.t f test n - the addrem.(tez):Amer, also s:earth mut •f this 1rsrtr. whist 30 clays of
14 :.ernple u of well roa rt all:in so Site eraint health dep the- i.+ems.�i'�`v _!' cjikialL ri. —} RS): _.:•;^ct"Ct^t2!'S. i
FoT tiW-I North Ccrotzna 0ep:•_•x ,.of 1 r:::r..--rtil erd Natewel ft,:•:-:t ie; `ssi.ion of Wc r i unlit? Ile sod Jan. i71
I
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via DOW sollueogut owetkamon
owner um
Neff
1 33 •
verridtAggSlaaB--Q-0--
mid"ceArthat the rameiefereind well via waned appearance litaccadancevatill
ell County Warden.
DkMerL-16J--"jd
Cerdikatit#: DdLJ
construcdotr &alit -
Total Depett—ALS:—
CaethglXxx—P-Voa—, Thicimiess: . •
. Exameter:
Wive Show
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