GW1--02136_Well Construction - GW1_20240409

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WELL CONSTRUCTION RECORD
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This form can be used for single or multiple wells For Iatetnal Use ONLY:
1.Well Contractor Information: I
Rex Meadows 14.WATER ZONES I I I
FROM I TO i DESCRIPTION ! -
Well Contractor Name ft. ft.
2113-A it. ft.
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NC Well Contactor Certification Number Ifk OUTER CASING(for multi-cased wells)OR LINER(If applicable)
FROM TO DIAMETER I' ' THICKNESS MATERIAL
Clearwater Well Drilling Inc. Ift• i M ft• (Oct l;�• I pUG
Company Name l(r.INNER CASING OR TUBING(Reotberniai dosed-loop)
FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: IL ft. ; ht.
List all applicable well construction permits(i.e.County.State.Variance,etc.) I
ft. ft in.
3.Well Use(check well use): 17 SCREEN !
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in
❑Geothermal(Heating/Cooling Supply) ;residential Water Supply(single) ft. ft. In. I
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT I I -
FROM TnnO MATERIAL I. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ( Oro CQ�e � 101)1�QV _
❑Monitoring ❑Recovery rt. ft' l. I I
Injection Well: • ft. ft. i I i
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable);, I -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO -MATERIAL'i t EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage R. R.
❑Experimental Technology ❑Subsidence Control I'
(Closed Loop) ❑Tracer
❑Geathe[tnal20.DRILLING LOG(attach additional sheets If necessary)
FROM TO ,DESCRIPTION(color,hardness,soil/rock type,grata size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) J r:. )�1 ft• c c�• t'V j-
4.Date Well(s)Completed:``-ng�~l�7 well ID# t�$ ft. 3 T um-AN_'e I
sa Well Location: 503 t1. 503 ft. Li i
E1 zf.(De C-4,- tvc o-\ -e 5- 50 3 r` 54FD rt. cyan i 8-
Facility/Owner Name Facility iD#(if applicable) .
ft. ft. !! ` I , •.D,.... a•i` ' ' er
1116 fix...!ts-9 6-- Mar-still I r. tt. i, I, I A c� ;, I
Physical Address,City,end Zipi 1QeR
F 4l X U�•1 son 21.REMARKS - ! I I `��,
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County ! aL:;i:,: :7"1 ? ^,.-;Q,u.'. I t •
Parcel Identification No.(PIN) i ' I D;,t,ciss1. f�5 `-J
Sb.Latitude and Longitude in h
gitn degrees/minutes/seconds degrees:
(if well field,one lat/long is sufficient) 22 erti atioD: i!
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7)5 i 4)° N ' �a,' I y-3 w V___-- ! --I lc -2,1
Si are of Certified Well Contractor 1 , i Date
6.Is(are)the well(s): Permanent or OTemporary
',\\ By signing this form,f hereby cet7�that thel well(s)xr{s(xaere)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 I 10 copy of this record has been provided to the wall owner.
If Ibis it a repah;fill out known well construction information and lain the nature alike Ii
repair under#21 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 additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction.lion.you can I
submit oneform. �+ l f- SUBMiTTAL INSTUCTiONS ' •
9.Total well depth below land surface: t� 4 5 at) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if differed(example-3®200'and 2 ti100') construction to the following:
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10.Static water level below top of casing: WO (ft.) Division of Water QnelityIt Information Processing Unit,
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water level is above casing.use"+" 1617 Mail Service Cente,:Raleig !NC 27699-1617
11.Borehole diameter: �.lC t i/ (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
1�Fv� y� above, also submit a copy of this fot`m;within 30 days of completion of well
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12.Well construction method: 1 wt 4 construction to the following: I I
(i.e.auger,rotary,cable,direct push,etc.) I' I i
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,iRRalelgh;NC 27699-1636
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13a.Yield(gpm) 3Q Method of test Q G 24c.For Water Supply&Injection Wells: In addition to sending the form to
l{ the addresses) above, also submit oriel copy of this form within 30 days of
13b.Disinfection type:Mi./brim Amount: .Gu-v►"2— completion of well construction to the county h th department of the county
where constructed.
Form OW-1 North Carolina Department ofEnvimmnent and Natural Resources—Division of Water Quality Revised Jan.2013
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