GW1--01086_Well Construction - GW1_20240216

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
Rex Meadows 14.WATERZONES 1 4
FROMTO DESCRIPTION I
Well Contractor Name rt. fL 1
2113-A H. ft. II
t
NC Well Contractor Certification Number 15.OUTER CASING(formula-cased wells)OR LINER1jf op liable)
P DIAMETER ' THICKNESS MATERIAL
V
• Clearwater Welt DrillingInc. / ft. fL to l in. I }(}V
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
} fl���'pl SiFROM
II.
DIAMETER+ THICKNESS MATERIAL
2.Well Construction Permit#: t v l' f. in. i'
List all applicable well construction permits(i.e.County,State,Variance,etc.) it H. in. I
3.Well Use(check welt use): 17.SCREEN i
Water Supply Well: FROM TO DIAMETER _SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public in. I
°Geothermal(Heating/Cooling Supply) tAtesidential Water Supply(single) R. R. in. I
Olndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT I
FROM TO MATERIAL• EMPLACEMENT METHOD&AMOUNT
❑Irrigation // ft. (90 IL L/)f// 1 n,�j J Err,
Non-Water Supply Well: t( t L I'�
R. ft
❑Monitoring ❑Recovery
Injection Well: H. R. I
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery °Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage rt. ft. 1
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if ncet nary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION Order,bndness,solurocktype.grain she.du)
°Geothermal(Heating/Cooling Return) 4❑Other(explain under#2l Remarks)_ /p IL 58 11. SOfid'itd'- i-
4.Date Well(s)Completed: I I -� Well Wit �7 / Y�'f
// /!$ � f(1/ I
5a.Well
D \Location: y c� 1 r?ft. r S R, tJfralti I
!�v1( ;1 f utS ) ft. of R. / I
Faccijlityy//OwnerNamen �`1�t� l Fa©cillitying(iff�applicable)
�,j ,.�, .i.,,' .,..
Lr; J( e oc\ ,O c C1�t til,L c)L rd r fL tL �E 11 f lE D
Physical Address,City,and Zip U.REMARKS I
1{ • 1P4 •
Vainon.f, ,
Ce ty Parcel Identification No.(PIN) Mit;i N.a ti2:It 4r^.� 1ng Om
5b.Latitude and Longitude in degreesiminutes/seconds or decimal degrees: 2T ,erti6 on: ,
(if well field,one tat/long is sufficient) t t.SS"' .1-XS & N S 1 �'( �`f(P WJ/ .. /-10 -Z3
Sign Certified Well Contractor I Date
6.is(are)the well(s): Permanent or ❑Temporary By signing this form.I hereby cerll&that the well(s)w (were)constructed in accordance
with 154 NCAC 02C.0100 or ISA NCAC 02C.0200 W l Construction Standards and that a
7.is this a repair to an existing well: ❑Yes orVo copy of this record has been provided to the well owner.
!f this is a repair,fill out known well construction information and explain the nature of the
repair under f12/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 additional well site details or well
8.Number of wells constructed: construction details. You may also attach additi Ial pages if necessary.
Far multiple injection or non-water supply wells ONLY with the same construction,you can
submit one farm. SUBMITTAL INSTUCTIONS 1
(
9.Total well depth below land surface: `-' (it.) 24a. For All Wells: Submit this form within 0 days of completion of well
For multiple hells list all depths Ifdderent(example-3@200'and 2@i00') construction to the following:
10.Static water level below top of casing: 62 v (ft.) Division of Water Quality,Informs on Processing Unit,
!farmer level is above casing.use"+'• 1617 Mail Service Center,Raleig ,NC 27699-1617
11.Borehole diameter: l J� l/' (iw) 24b.For Injection Wells: In additi s n to sendin the form to the address in 24a
above, also submit a copy of this form within 0 days of completion of well
12.Well construction method: i1)fa 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 27699-1636
/`� 24c.For Water Suppiv&infection Wells: In addition to sending the form to
13a.Yield(gpm) V •Method of test: the address(es) above,also submit one copy this form within 30 days of
13b.Disinfection type: Amount completion of well construction to the county ealth department of the county
where constructed.
Form OW-I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013

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