GW1--01804_Well Construction - GW1_20240320

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY: i
1.Well Contractor Information:
• Rex Meadows 14.WATERZONES i 1
FROM TO DESCRIPTION
Well Contractor Name ft, ft. I I
2113-A ft. It I ; '
NC Well Contractor Certification Number 15.OUTER'CASING(for multi-cased wells)ORLINER Of ap ncable)
FROM TO ' DIAMETER, THICKNESS MATERIAL 1
Clearwater Well Drilling Inc. 1 it. r5�1. ft. ts ti In. I S¢P e 1
Company Name 16.INNER CASING OR TUBING(geothermal dosed loop)
\
� FROM TO DIAMETER THICKNESS - MATERIAL2.Well Construction Permit#: a; rt. is
List ell op/it/cab/ewe!!constructionpermits(i.e.Comm State.Variance,etc.)
O. Q. to.
3.Well Use(check well use): 17.SCREEN
•
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural ❑MunicipallPubiic ft. In. •
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R- [L in
❑lndustriaUCommetcial °Residential Water Supply(shared) Ig.GROUT_ i
FROM TO - MATERIAL EMPLACEMENT METHOD&AMOUNT
°irrigation"
Non-Water Supply Weil: I ft. •Op ft e(fill ilt Mi U
°Monitoring °Recovery ft. 1 ' I�,i `
injection Well: R, ft.
°Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK(if aponcablc)
°Aquifer Storage and Recovery ❑Salinity Barrier ,FROM TO MATERIAL I EMPLACEMENT METHOD
ft. ft
°Aquifer Test CStormwater Drainage
°Experimental Technology °Subsidence Control it, A. I I
°Geothermal(Closed Loop) O7m 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(calor,tiardacst,salt odktypgRtaini¢aeta)
❑Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks)- I it $f n- a.Jln •}-1C,(,'r.-
4.Date Well(s)Completed: o2�'o�4 Weil ID# t11� it �rl O ft (rani i; �'"' 's tee' i
n0 ft. n 1 ft. (`JberthL,Q I 6 ``-.Pt,..-e V 1..,L..
5a.Well Location: ;! p n l ft. 2AS IL c►ra�l I 19 204
MCI X e.-)37!�. V,v1 an R. R. J ; !V)Ai�
Facility/Owner Name Facility lDii(if applicable) 74,'v'kn s LRri
D(.O 'SC.ronee Cree>r QD . `t. �- t�ls,,;ta:�:c�m;=.-A,. :.ta
ft. ft, (
Physical Address,City,and Zip 21.REMARKS I
.01n1/4)Lrreti
C ty Parcel Identification No.(PiN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22. tcation: t
(if well field,one lat/tong is sufficient)
•
D• 9' I 3'-i- . 5?' ' (99 A53
Signat of Certified Well Contractor 1 Date
6.Is(are)the well(s): Pkermanent or ❑Temporary
By signing this form.I hereby ca l&that the urll(s)inns(lyre)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC,02C.0200 Well Construction Standards and thin a
7.Is this a repair to an existing well: °Yes or t to coPy ethic record has been prmddcd to the well owner
!Phis Is a repair,fill out known well construction b formation and plain the nature afthe '
repair under 021 remarla section or on the back of thisfornr. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
B.Number of wells constructed: construction details. You may also attach additi nal pages if necessary.
For multiple injection or non-ureter supply wells ONLY with the same construction.you can I'
submit ancfirm. 11 SUBMITTAL INSTUCTiONS
9.Total well depth below land surface: t ll�l (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ftGferent(erample-3G00'and)100) construction to the following: I,
1
10.Static water level below top of rasing: LPD (ft) Division of Water Quality,;information Processing Unit,
If uoter Irel is above casing,rise"+" I 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: w% (in.) 24b.For Infection Wells: 1n addition to send'I g the form to the address in 24a
above,also submit a copy of this 4 form wn 30 days of completion of well
12.Well construction method: rD+C construction to the following
(Le.auger.mtary,cable,duectpush,etc.)
Division of Water Quality,Underground injection Control Program,
FOR WATERSUPPLY WELLS^�� ONLY: 1636 Mail Service Ce}nter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method or test: 9)9 24c.For Water Supply&In)ectionhlVell1: In addition to sending the form to
the address(es)above,also submit one copy of this form within 30-days of
fib.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed. �I
Form OW-I North Carolina Department of Environment and Natural Resources-.Division of Water Quality Revised Jan.2013

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