GW1--00594_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
Well Contractor Name ft, ft.
2113-A ft. ft. I I .
IS.NC Well Contractor Certification Number OUTER CASING(for multi-easedETwells) KR SS(If pp Qepbte)
FROM TO DIAMETER THI KNFSS MATERIAL
Clearwater Well Drilling Inc. \ n. © ft. tp`\Vn. c)VC
Company Name 16.INNER CASING OR TUBING(Reuther Ifl l rloskd-loop)
� V�� FROM TO DIAMETER THICKNESS MATERIAL,
2.Well Construction Permit it: '20�1 O ft. ft. ia.
List all applicable well construction permits(i.e.County.State.Variance,etc.) ff, ft. in.
3.Well Use.(check well use): 17.SCREEN
FROM TO DIAMETER SLOTSIZEI THICKNESS MATERIAL
Water Supply Well: fL ft. In.
❑Agricultural ❑MunicipaUPublic
ft, R. In.
OGeothermal(Heating/Cooling Supply) 'itesidential Water Supply(single)
❑lndustrial/Commetuial OResidential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 1 ft. eQD ft* c el—, - I m la C
Non-Water Supply Well: It. ft. I
❑Monitoring ORecovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(If applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft. 1 I
❑Aquifer Test ❑StormwaterDrainage ft. rt.
['Experimental Technology ['Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothen-nal(Closed Loop) ['Tracer FROM TO DESCRIPTION(color,Madness.sONrack(TPA.groin ahe.dc•)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 821 Remarks) t ft• I0 it- � �1(.t 4 adi If4-
4.Date Well(s)Completed: ell ID# i VA n, l 4'0 ft f e i c)
5a.Well Location: 1�0 it
tS ft. (y (
C.OW\)C X i --rUCIx ft. R.
��,
Facility/(hvnerl�lame Facility IDR(if applicable) ft. ft. t
-V) ( 7 OX CCU-N1 'd t eanGW'Y ft. ft
Ph steal Address,City,and Zip lam/(/ 21.REMARKS I J`-,N x .0 2024
uv111.-cam arm.
County
Parcel Identification No.(PIN) jr"v.: ^� 4 SO(y
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22. dinlion:
Orwell field,one latllong is sufficient)
(9a ' Gl3 NT 14) ► col W 1‘-i5-4a
Signet ed Well Contractor Date
6.Is(are)the well(s):Aermanent or CiTemporary By signing this form.I hereby certii .that the well(s was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards mid that a
7.Is this a repair to an existing well: ❑Yes or _ i to copy of this record has been provided lo,the well DIM r.
If this is a repair,j ll out known well construction information and explain the nature of the Site diagram or additional well details:
repair wider HI)remarks section or on the back of thisfarm.
You may use the back of this page to provid additional 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 hells ONLY with the same construction,your can submit one form. I SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths ijdifferenl(example-3@200•and 2 10(r) construction to the following: I
10.Static water level below top of casing: .0 • (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing.use'-++" 1617 Mail Service Center,Raleigh,NC 27699-1617
L rQ
11.Borehole diameter: l V (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
vn_(� above,also submit a copy of this form within 30 days of completion of well
12.Well construction method: 1 l T[_itc construction to the following:
(i.e.auger.rotary,cable,direct push,etc.) 1
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY W
Method of test ellELLS ONLY: 24c. &1636 Mail Service Center,Raleigh,NC 27699-1636
dv For Water Supply Injection Wells: n addition to sending the form to
13a Yield(gam) the address(es) above, also submit one cop of this form within 30 days of
completion of well construction Ilto the county health department of the county
13b.Disinfection type: Amount where constructed.
Form OW-1 North Carolina Department of Environn ent and Natural Resources—Division of Water Quality Revised Jan.2013

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limey cad*that the above referenced well was grouted ilk appesanoein- with
all County Wellies.
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Certiftcal Thapekouted: a
CAMSUUCliOD: GM*
Toud Depthjia,
Type
Cask*TYpe:-W.C. -- Tharkess: bz-L
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