GW1--00704_Well Construction - GW1_20240125

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
t
Rex Meadows 14.'WATERZONES - i I I
FROM TO DESCRIPTION I
Well Contractor Name ft ft.
2113-A ft• ft.
NC Well Contractor Certification Number IS.OUTER-CASING(for multl-cased_welli)OR LINER(if an ncable)
FROM TO DIAMETER I THICKNESS I MATERIAL ,
Clearwater Well Drilling Inc. / R- LPr . • %�f
Company Name "MANNER CASING OR. 0 /ginR TUBING(geothermal clas4d-loop) _�PVC'
FROM TO DIAMETER '. THICKNESS MATERIAL
2.Well Construction Permitli: ft. ft. I,in.
List all applicable nal!construction permits(i.e.County.State.Variance.etc.)
It. ft. ,in.
3.Well Use(check well use): 17.SCREEN I. '
Water Supply Well: j ) FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
agricultural —Fet ry, kid/ ❑Municipal/Public R. ft. in.
❑Geothermal(Heating/Cooling Supply) []Residential Water Supply(single) ft. rt. in.
❑lndustrial/Commercial ['Residential Water Supply(shared) 1&
FROM GROUT TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: -
l IL D C•�'�` 3`I �-'/ a
❑Monitoring ❑Recovery R• ft.
Injection Well:
ft. R. '.
OAquifer Recharge ❑Groundwater Remedietion 19.SAND/GRAVEL PACK(ifapplicable)' I
FROM TO MATERIAL ' I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier B. R. I'
❑Aquifer Test ❑StormwaterDrainage R. R. 1
❑Experimental Technology ❑Subsidence Control I,
20.DRILLING LOG(attach additional'sheets If nee )
DGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color.hiJdness,son/rock tRe.t rala stye,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) / ft' W3 ft* lcIGti1'/a. - 69
j�
4.Date Well(s)Compleetteed:/2• /�43Well D11 /(a � �
Well Location: I—✓ anal./ /�� rt /1 rt � u-
ses. � t/3 f. / SfG a� le
HozeiS Ire _
Facility/Owner Name f m y �,f� Fa•ity ID#(if applicable)� •a-� m
//tt W.♦2c � t�At�, ✓r ! R, ft 11 w 4 V + O
�g R. ft
Physical ifddff�s,�Cnity,and Zip /' I �A N 2 5 202'
t�C' I/ �`-� 21.REMARKS
County Parcel ldentiicationNo.(PIN) ln`�• ?- ._.,-.--2 E.!rU
: vi+ain'
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Ce 'ICa '
(if well field,one lat long is sufficient)
�° 071/67 N ; r r
-73q$) W l -a7-a3
Signal; of :;' ed Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary
By signing this form.I hereby certlfr that the stall(s)WU(here)constructed in accordance
with ISA NCAC 02C.0100'or ISA NCAC 02C.0200 Well 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 ouster.
If this is a repair,fill out known well construction Information Ai:
the nature ofthe
repair under#21 remarks section or on the back of this farm. 23.Site diagram or additional well details:
You may use the back of'this page to provide aeditional 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-natersupply wells ONLY with the same construction.you can I,
submit one form. _ SUBMITTAL INSTUCTIONS
9.Total welt depth below land surface: /FJ (tt) 24a. For All Wells: Submit this form within 30 days of completion/Of well
For multiple wells list all depths ifdi(jerent(example-3(l200'and 2Q100) construction to the following: i.p '\ ./
10.Static water level below top of casing: LID (ft) Division of Water Quality,lnformatio__ -toegssut�Unit,
If water level Is above casing,use"+'• I 1617 Mail Service Center,Raleig ,N 2 99-1617
/
II.Borehole diameter: (. /8' (in.) 24b.For Iniection Wells: In addition n to sendi g the form to the address in 24a
{� ��/f j� above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: /(J* —. _! construction to the-following.
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Quality,Underground Ipjeetion Control Program,
FOR WATER SUPPLY WELLS ONLY: r 1636 Mail Service Ce;lei;Raleig(r,NC 27699-1636
r
13a.Yield(gpm) t J Method of test: / 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es)above, also submit one copy o'this form within 30 days of
13b.Disinfection type: Amount completion of well construction to the1 county health department of the county
where constructed.
Form OW-I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013