GW1--02134_Well Construction - GW1_20240409

11
WELL CONSTRUCTION RECORD Far Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Rex Meadows Id.WATER ZONES III
FROM TO DESCRIPTION I I I
Well Contractor Name ft. ft. I I
2113-A ft. ft. I 11
NC Well Contractor Certification Number i 1.ni OUTER CASING for multi-cased wells)OR LINER Of ap cable)
FROM TO DIAMETER 1 I' THICKNESS MATERIAL
Clearwater Well Drilling Inc. (i5 ft' VD t1`6 lit. ' I ; r
Company Name 1d.INNER CASING OR TUBING(geothermal closed-loop) V
FROM TO DIAMETER 1 THICKNESS MATERIAL
2,Well Construction Permit#: IL ft. in.I
List all applicable well construction permits(Le.County,State.Variance.etc.) _
ft. f. Im
3.Well Use(check well use): 17.SCREEN I I
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. R' la
['Geothermal(Heating/Cooling Supply) XResidential Water Supply(single) IL fL in.
❑Industrial/Commercial ['Residential Water Supply(shared) I&GROUT I
FROM TO MATERIAL I" EMPLACEMENT METHOD&AMOUNT
❑Irrigation /� �� y d
Non•Water Supply Well: �D C-K 11 1��It Ph1
DMonitoring ❑Recovery
Injection Well: • IL ft I
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Of applicable) I I
DAquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL I; EMPLACEMENT
METHOD
ft. ft. ; I
DAquifer Test ❑StormwaterDrainage ft. ft.
DExperimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
OGeothennal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soli/rock type,main afro,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain tinder#21 Remarks) n• J i 5 It. N c r.�
4.Date Well(s)Completed 3—t2"Z 4 Weil ID# �� tt. �� ft. r�,�11v Ili
S DIP rt. bi1 IL , iffeA IV
1�.
Se.Well Location: S ICkm( �' S�1 fL 05 fl. a.y�ej�.
FaVVi \1eti 3-Q/ 1 ft. R. r `1I I`
Facility DM(if applicable) ft. ft
\M PDt: i ' k 1^`
Ph icel Address,City,end Zip 21,RF11lARES d' tvr L.i il' I'"'3
t��Gl�t�h n D �. 24
County Parcel Identification No.(PIN) ; I ' tI ` t(I
nq
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: ,Cerd ation: It)�;Cr'"•' "', ^:
jn
3 dwell field,one let/longis sufficient :;'
�� )N a:' ` �� S W �;b� : -�e -1 —a
Sign are o ertified Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form.I hereby cet7ifi,that the I well(s)wa (were)constructed in accordance
with I5A NCAC 02C.0100 or ISA NCAC 02C1,0200 iWel Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or KNo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 1121 remarks section or on the back of thisform. 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 additional pages if necessary.
For multiple Injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS •
9.Total well depth below land surface: .D OS (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example.3®200'and 2®100) construction to the following.
10.Static water level below top of casing: lQ 0 (ft,) Division of Water Quality,Information Processing Unit,
If water level is above casing.use"+t ^t t 1617 Mail Service Centn.
i r,1 Raleigh NC 27699-1617
11.Borehole diameter: L41 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
{�f\.(-/� �(� a above, also submit a copy of this form'within 30 days of completion of well
12.Well construction method: 1 v 1 0.. `I construction to the following:
II
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground(ground In action Control Program,
FOR WATER SUPPLY WELLS ONLY: O 1636 Mail Service Center,Rale(gh,J NC 27699-1636
13a.Yield(gpm) 3 Method of test: q 24c.For Water Supply&Infection Wells: In addition to sending the form to
�j, 'n�� q y� the address(es) above, also submit on6'copy of this form within 30 days of
13b.Disinfection type:C 1.1 b 11 Y U, Amount: q ounces completion of well construction to the county h th department of the county
where constructed.
l
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
1

• WilleiellitaiNtierootCordikaillon .
.c.hodY-)Cte-ne,r korrler?
T.Ob
Nw** . -
'
. •
Pereitt.
t1er4totitiblit1eabatterefereaced weflwud inappeumwerin accord**with
alltematyWalindes.-
Well MTh= Vex Mead et0.5
cetecom a Disommtga;
amttrucdta .orao: •
. more* l_co l'Ipm2a04-f)\-
castierype.. Imm• o:
..mingDare: . rigat___43.2__
. Diameter; . .•
I •
ariVegine
OPMf,
,•
• 11 .
•
•
•