GW1--00533_Well Construction - GW1_20240118

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: '
14.WATERZONES I 1
Rex Meadows FROM TO DESCRIPTION I
Well Contractor Name [t. ft. I
2113-A f. ft. I
15.OUTER CASING(for multi-cased wells)OR LINER(if ap Itcable)
NC Well Contractor Certification Number FROM TO DIAMETER I THICKNESS MATERIAL
Clearwater Well Drilling Inc. ft UQ\ ft. lQtk in.
IV)().)
Company Name 16.INNER CASING OR TUBING(geothermal closdd-loop) -
Pan n ► A J y t ��� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: g CAA ("tl f. ft. in. I
List all applicable well construction permits(i.e.Coun%State,Variance.etc.) ft ft. in. 1
-
3.Well Use(check well use): 17.SCREEN . 1
FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
Water Supply Well: ft, ft, in.
❑Agricultural OMunicipal/Public
it. R. in.
°Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
❑Residential Water S 1
❑Industrial/Commercial upp y(shared) 18.GROUT( FROM TO MATERIAL. EMFLACEAIENT METHOD&AMOUNT
❑irrigation , ft. ft. 0ecnOf- tc` l)
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
°Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) I
FROM TO MATERIAL EMPLACEMENT'METHOD
°Aquifer Storage and Recovery ❑Salinity Barrier tr. rt.
°Aquifer Test ❑StormwaterDrainage i. It. I
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(cnior,bdrduesa.soiilrnck liFe,grain size.etc.)
i
❑Geothermal(Heating/Cooling Return)sl -°Other(explain under#21 Remarks) \ ft- .0 k, C�;ft. A y/
``- N-. Well lD# t Q 1 f�`Act it. {je
4.Date Well(s)Completed: V�q it, Qc L��ft. N ui LQ
5a.WellLocation: _1a)r. :a oS f. /�{( G, It'
Facility/Owner Name Facility IOU(if applicable) { i j
v� � du
3 1- � M-t-� . Yl C TIL ft. ft. :.0 `�e,
Physical Address,City,and Zip �C...- 21.REMARKS i R C• •ii s (U2.4
.
I r �+�7 ..
County Parcel identification No.(PIN) cm...�.a,Tinta r a u^w"la"
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: Cer fication:
(if well field,one tot/long is sufficient) 0 , 1 1` ��
` 84 i�Dn N CAA' a0 �`� �w i.ti ` 1
Si edified Well Contractor Date
6.Is(are)the yvell(s): ermanent or °Temporary By signing this form,I hereby cerlify that the well(s)LI1
as(were)constructed in accordance
with ISA NCAC 02C.0100 or iSA NCAC 02C.0200 Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or ') No copy of this record has been provided to the well mote
If this is a repair.fill out known well construction information and captain the nature of the
repair under litl remarks section or on the track of thisftrm.
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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can SUBMITTAL INSTUCTIONS
submit one form. C
9.Total well depth below land surface: ratrr��(Q lJ (ft.) 24a.For All Wells: Submit this form with n 30 days of completion of well
Far multiple wells list all depths if different(crumple-3@200'and 2@100') construction to the following:
10.Static water level below top of Casing: w 0 (ft.) Division of Water Quality,information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
If water level Is above casing.use'"+"
11.Borehole diameter: lO t' (fn.) 24b.For Iniection Wells: In addition to sen ing the form to the address in 24a
( above,also submit a copy of this form wit n 30 days of completion of well
12.Well construction method: 1 V 1�k4 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,Rat"gh,NC 27699-1636
I
24c.For Water Supply&Iniection Wells: addition to sending the form to
13a.Yield(gpm) Method of test: the address(es) above, also submit'one cop) of this form within 30 days of
Amount: completion of well construction i o the county health department of the county
13b.Disinfection type: where constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Ian.2013

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