GW1--00528_Well Construction - GW1_20240118

I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: I
14.WATER ZONESI
Rex Meadows - FROM TO DESCRIPTION
Well Contractor Name R. n'
2113-A ft, ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi.cased:we➢s)OR LINER(if upQQlivable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Welt Drilling Inc. ft. ft. in.
Company Name /� 16.INNER CASING ORTUBING(geothermal cl ed-loop)
T b\c.c oq( y FROM TO DIAMETER` TFI MESS MATERIAL
Well Construction Permit#: IVI�/i �/� fr. ft. ; in.
List all applicable well construction permits(Le.Co unry,State.Variance.etc.)
ft. ft. 1 in.
3.Well Use(check well use): 17.SCREEN I
Water Supply Well: FROM TO DIAMETER.. SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public R'
Geothermal(Heating/Cooling Supply) (]Residential Water Supply(single) rt. ft. in.
❑Industrial/Conunercial ❑Residential Water Supply(shared) IS.uo GROUT TO MATERIAL EMPLACEMENTt METHOD&AMOUNT
❑irrigation ft. ft.
Non-Water Supply Well:
R. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(ff applicable) I
UAquifer Storage and Recovery ()Salinity Barrier FROM ft. TO ft. MATERIAL I EMPLACEMENT METHOD
i
❑Aquifer Test ❑Stormwater Drainage
-
n. ft.
❑Experimental Technology oSubsidence Control
20.DRILLING LOG(attach additional sheets If necessary)
❑Geothermal(Closed Loop) OTracer .FROM TO (c
olor,color,hardness,salt/sue c type,grain size,etc)
❑Geothermal(Heating/Cooling Return) OOther(explain under#21 Remarks) 0 n. ,3
i 29)R' a e vV�l " 1 a
1- , R. .
4.Date Well(s)Com let el IN nTDIA.1- 4. San Cii
ft. ft. t
Sa.Well Location: Co ft. ft. ,r.r', , r a
VV 11\�(` n� Q� � 61\kf2> rt. ft. t z `' �-Facility/OtvnerName Facility ID ( livable) JAN Y 8 LUC`t
321 &In V�1� y fv01 ) ft. t. i�
Physisal.Address.City,and Zip 21.REMARKS 't n"•'',:r-w e V. °:n_z=
i
�CLSon
County Parcel Identification No.(PiN)
5b.Latitude and Longitude In degreeslminutes/seconds or decimal degrees: 22.Ce till lion:
3(if well field,one 1stllong isis sufficient)ufgie �( a 1\' `h,1 ll�J��) /^ l
tom{ ,rl o Vt U 3 \ \ V\ • Vv W `� `_- , 3E.)
Signat rtified Well Contractor Date
i
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form.I hereby certifi.that the wells)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Veil Construction Standards and that a
7.is this a repair to an existing well: Oyes or D copy of this record has been provided to the well mow;
If this is a repair,full out known well construction information a d lain the nature of the
repair under 1121 remark section or on the back o thisfor 23.Site diagram or additional well,details:
� You may use the back of this page to provideladditional well site details or well
8.Number of wells constructed: 1 f `7T) construction details. You may also attach additonal pages if necessary.
For multiple infection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS ,
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form with n 30 days of completion of well
For multiple wells list all depths ifd jTerent(example-3C200'awl2@I00) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Quality,Info lion Processing Unit,
Ifwaterlevel is above casing,use"+" 1617 Matz Service Center,Rale gh,NC 27699-1617
11.Borehole diameter: (in) 24b.For Injection Wells: In addition to sen ing the form to the address in 24a
above,also submit a copy of this form with n 30 days of completion of well
12.Well construction method: construction to the following:
(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,Rai gh,NC 27699-1636
13a Yield(gpm) Method of test 24c.For Water Supply&Injection/Wells: addition to sending the form to
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to ithe coon health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013