GW1--00670_Well Construction - GW1_20240125

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells JFor1ntcl Use ONLY:
1.Well Contractor Information:
i
Rex Meadows 14.WATER ZONES 1 i
FROM TO DESCRIPTION
Well Contractor Name ft ft I
2113-A ft. R. I . I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR DINER(if op !feeble)
FROM I TO DIAMETER i THICKNESS MATERIAL
Clearwater Well Drilling Inc. l n. II--) it 11Shu I pVL
Company Name t6.INNERCASINGORTOVI
G(geothermalelGaed-loop)
4
' e l FROM TO DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit#: ra j � — I u 11.o) it. ft. in. I -
List all applicable well construction permits(Le.County.State.Variance,eta)
ft. ft i' in. I
3.Well Use(check well use): 17.SCREEN
I, 1
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Cl Agricultural ❑Municipal/Public R' n' i°''` I
l7Geothennal(Heating/Cooling Supply) residential Water Supply(single) ft. R• in.I, I
❑Industrial/Conunercial ❑Residential Water Supply(shared) 18.GROUr 1 I
FROM TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
Mitigation -t— '�^ , 1
Non-Water Supply Well: 1 f ..e • R' C 1 'I �1 1 ►y�Q�JtC V
OMonitoring ❑RecoverY R. R.
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19;SAND/GRAVEL PACK Of applicable) . I
['Aquifer and RecoveryFROM TO MATERIAL . I EMPLACEMENT METHOD
Storage ❑Salinity Barrier
OAquifer Test ❑Stormwater Drainage ft ft,
ft. R.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tm 20.DRILLING LOG(attach additional sheets ifneecssary)
FROM TO DESCRIPTION(color,hardness,soIumck type.gin size,eta)
❑Geothermal(Heating/CoolingR'eturn`) ❑Other(explain under#21 Remarks) I ft. 1 ! f• S /tlI4- cusv-i--
4.Date Well(s)Com leted: I o(-I I -93%11 ID# (���tttt �'�,Q�+ - �l .Q1 I tI L
• Sn.Well Location• C X �� a J9(Q 1QWTA xt.e
I r-+ r 1+- W es-�- 1Losft (ram w,c I
Facilinty//Ownneer�Naame �+� Facility 11D0(if applicable) t
Sect 1T Rd ► eil-d-r-)p AA n R. ft , 'a. ft. !ice L/
Physical Address,City,and Zip 21.
County I Parcel identification No.(PiN) �
infiO;TrF ''1 t�S^t SE�ikFsl Ufa
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: ,( y' ;
given field,one Lit/long is sufficient) , ,
2.Certifi lion:
35` a` 6'11 N S t-� (Doy' W _ , 1 Z-k` -z)
Si we. eitified Well Contractor f Date
6.Is(are)the well(s):ytermanent or [Temporary By signing this fem..i hereby ceritfr that the wells)nag(were)constructed in accordance
Ivh iSA NCAC Q2C.0100 or ISA NCAC 102C.0200111e0I 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 ouster.
If this is a repair,fill out known well construction Information and explain the nature of the I
repair under#2I remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide ac ditional 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 we/is ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 1 U1 (IL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdiJferent(example-3®200'and 2Q100) construction to the following: r
10.Static water level below topof casing: I
v (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" t 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (...0
(in.) 24b.For Injection Wells: in additionto sendinlg the form to the address in 24a
i above,also submit a copy of this form within 30 days of completion of well
�
12.Well construction method: Ccf phLe construction to the following: `{
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: /� 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
13a,Yield(gpm) 1 Method of test: ibl`GI, 24e.For Water Supply&Injection Wells: In addition to sending the form to
the address(es)above, also.submit one copy oil 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 Jan.2013