GW1--00535_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.WATER ZONES I
Rex Meadows FROM TO DESCRIPTION I
Well Contractor Name ft. ft. I I
2113-A ft. ft. . I
NC Well ContractorCerificationNumber IS.OUTER CASING(for multtcased wells)OR LINER(If ap !Rabic)
FROM TO DIAMETER ' THICKNESS MATERIAL
Clearwater Well Drilling Inc. 1 R. %0 ft. VQ srk `"" I \>ve .,
Company Name 16.INNER CASING OR TUBING(Reothermnl dosed-loop)
�(1 01 j 1�f FROM
ft.
Et. DIAMETER, THICKNESS MATERIAL
2.Well Construction Permit#:_ 1�--ih in.
r
List all applicable well construction permits(i.e.County.Slate.Variance,etc.) ft. ft. In.
3.Well Use(check well use): 17.SCREEN
FROM TO DIAMETER ,SLOT SIZE I THICKNESS MATERIAL
Water Supply Well: ft. ft. in.
°Agricultural ❑Municipal/Public
°Geothermal(HeatingiCooling Supply) ytesidential Water Supply(single)
ft. ft. in.
°IndusttiallCommercial °Residential Water Supply(shared) is GROUT
FROM TO IItATERL1t. EMPLACEMENT M OD&AMOUNT
°Irrigation 1 it. cap ft. 1.C.1 1 1e, i �(�` III
Non-Water Supply Well: ft. ft. a ,
❑Monitoring °Recovery
Injection Well: ft. R.
°Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK Of applicable)
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Denier ft. R.
°Aquifer Test ❑StormwaterDrainage ft. tL
°Experimental Technology OSubsidemce Control 20.DRILLING LOG(attach additional sheets if necessary)
°Geothermal(Closed Loop) °Tracer FROM TO DESCRIPTION(eotor,badness,sowmek g grain strgde.)
❑Geothermal(Heating/Cooling Return) °Ather(explain under#21 Remarks) ( fte R /� �(j I
• 2 u . C��M 1 !
j
4.Date Well(s)Completed: 1" " ell so ft. ���R• CYafli
ID# so R. Rol ft. aexA.4I
SA.Well Location: —1(0.1 IL ft. ICVM-IC!�
Coos i1Ch it. ft.
Facility/OwnerName Facility IDS(if applicable) _ Q,.r.
Sea A 1,/r . V 3aves\A ttL ft. ft. , '1, ,,.4w..D tt._t e4 e L.y
Physical Address,City,unll Zip 21.REMARKS • 1 J �, (� 2o't1�4
kit \true 1
Parcel Identification No.(PIN) +
County . .. -n P,.-c �<'��J C:•��: CI:once
11+,V.�n.'DWl.J'J�.J�Sb.Latitude and Longitude iD degreeslminutes/seconds or decimal degrees: 22.Ce tifi ation:
(ifwell field,o�nejl�aViang is sufnfiiciennt) Q • ` -i Cri I b1XlY N ) 14 1\ W 11 JSipa ofC ' e Contractor Dateb.IS(are)the well(s): Permanent or °Temporary By signhtg this form,I hereby cert thdt the ne!/(s) +as(were)constructed in accor
with!SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Tell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or iNo copy of this record has been provided to the well unner+
!phis Is a repalr.Jill out known well construction information a d explain the nature of the 23.Site diagram or additional well details:
repair under VI remark section or on the back of this form.
You may use the back of this pagelto provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
Far multiple injection or non-water supply nulls ONLY with the same Construction.you can SUBMITTAL 11VSTUCTIONS
B..b,..:i o..o fan,.9.Total well depth below land surface: )5 (ft.) 24a. For All Wells: Submit this•form with 30 days of completion of well
For multiple wells list all depths if different(example-3C200'and 2(j)100') 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 "II co 1617 Mail Service Center,Ralegh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sen ing the form to the address in 24a
'�A� above,also submit a copy of this form with 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: l 1636 Mail Service Center,Ral ugh,NC 27699-1636
`-� Method of test ._i O 24c.For Water Supply&Iniectioin Wells: hi addition to sending the form to
13a.Yield(gum) the address(es) above, also submit one cop�of this form within 30 days of
completion of well construction to the coon health department of the county
Amount:
13b.Disinfection type: where constructed. 1
Form OW-I North Carolina Department of Envirommnt and Natural Resources-Division of Water Quality Revised Jan.2013

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mere*catlfytbat the above refeleloal well was pond in appearance*accordituarnith
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