GW1--00556_Well Construction - GW1_20240125

I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Information:
Rex Meadows 14.WATER ZONES .
FROM TO DESCRIPTION i
Well Contractor Name it (t,
2113-A ft. ft.
,
NC Well Contractor Certification Number 15.OUTER CASING(formula-cased Wells)OR LINER(if ap !table)
FROM T DIAMETER TIW KNESS I MATERIAL
Clearwater Well Drilling Inc. / ft. qb iL (// In. ,0Va
Company Name 16.INNER CASING OR TUBING(geothermal doted-loop)
11�2 �p} �� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: , O 3 w 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.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZH THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public it. ft. in.
❑Geothermal g/ g Supply) Supply(single) it, ft. in.
(Hearin Coolie Su 1 Residential Water
❑lndustrialICommercial ❑Residential Water Supply(shared) l&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation / it 20 IL /)� l Imo,,, die /�'/
Non-Water Supply Well: L y /�/J J�-�(1
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(If applicable) I
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
ft, ft.
❑Aquifer Test ❑StormwaterDrainageR. R.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if nceeasary)'
°Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color.!titaness,solUrock type,main size,etc.)
❑Geothermal(Heating/CoolingRetufrn) �l❑Other(explain under#21 Remarks) / ft' qo ft. S' )L �"-/-
4.Date Well(s)Completed: /t9`/'pl ell ID# �`'ft. ° %l /� � �'l
z9/ {39a� cf I
Sa.Well Location/:/ '/aft Vg5 it IDOD /' li 1ders ft ft924A/reI
Facility/Owner Name Facility 1D#(if applicable) ft. ft
// Oews D1-. e/iiidile.r. A/6 ft. ft. rV,,
Phy 'I Address,City,and Zip 21.REMARKS I ^-•�.�
, (J?�7ftJ2? JN\I 2 5 7024
County Parcel Identification No.(PIN) �/
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Cer'Rcahon: ,...., •1 0 '
(if well field,one latllong is is sufficient) I I..Ql3f'f J
3[�t Ul i tot) N 8-0) "T �/�CJa W I d� -,w-P) g
J ignature of Certified Well Contractor ' Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form.I hereby cent that the well(s)w (were)constructed in accordance
\ with ISA NCAC 02C.010U or ISA NCAC 02C.0200 w 0 Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or so copy of this record has been provided to the well owner.
If this is a repair,fill out!brown well construction information an explain the nature of the
repair under#21 remarls section aeon the back af this farm. 23.Site diagram or additional well details:
You may use the back of this page to provide a ditional well site details or well
B.Number of wells constructed: construction details. You may also attach additi al pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construcion,you can
submit one form. sJ� SUBMITTAL INSTUCTIONS
[�
9.Total well depth below land surface: //.Z (fo) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdderent(example-3 00'and 2@l00) construction to the following:
'n 1
CIA 10.Static water level below top of casing: O (ft.) Division of Water Quality,Informs on Processing Unit,
If water level is above casing.use'+" (G 1617 Mail Service Center,Raleig ,NC 27699-1617
11.Borehole diameter: CL' /0 (in) 24b.For Injection Wells: In addition to sendin the form to the address in 24a
/7)f/h N ' above, also submit a copy of this form within 0 days of completion of well
12.Well construction method: I i/T/.(�/(/J construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) i
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,ter,Raleig NC 27699-1636
• Fo
r or Water Supply&Injection Wells: In a dition to sending 13a.Yield(gpm) 096 Method of test the form to
4
the address(es)above, also submit one copy oft this form within 30 days of
13b.Disinfection type: Amount completion of well construction to the county health department of the county
- where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Ian.2013