GW1--02137_Well Construction - GW1_20240409

WELL CONSTRUCTION RECORD I
This form can be used for single or multiple wells Fat Internal Use ONLY:
1.Well Contractor Information:
Rex Meadows 14.WATER ZONES I I I
FROM TO DESCRIPTION' I
Well Contractor Name ft. ft.
2113-A It, ft. I I
NC Well Contractor Certification Number l OUTER CASINO(for multi-cased wens)OR LINER Of applicable)
FROM TO DIAMETER I 1' THICKNESS MATERIAL
Clearwater Well Drilling inc. 1 it. 5a ft. Le l 8 ,ni, 1 Na
Company Name Il -INNER CASING OR TUBING(neothermal elosed-loop)
FROM TO DIAMETER'; I THICKNESS MATERIAL '
2.Well Construction Permit#: ft. ft. in:
' I
List all applicable well construction permits(i.e.County.State.Variance,etc.)
iL B: I
3.Well Use(check well use): 17.SCREEN 1 II
Water Supply Well: FROM TO DIAMETER SLOT SIZE) THICKNESS MATERIAL
C]Agricultural ❑Municipab'Public it, ft. In.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. In
Dlndustrial/Coinntercial ❑Residential Water Supply(shared) lit.GROB I
FROM T TO MATERIAL. I EMPLACEMENT METHOD&AMOUNT
°irrigation B' ao i. eo riv Mild _
Non-Water Supply Well:
fL IL
°Monitoring ❑Recovery
Injection Well: • IL ft. ;
❑Aquifer Recharge ❑Groundwater Remediation 10.SAND/GRAVEL PACK pf appilcebleeJ
°Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I I EMPLACEMENT METHOD
iL ft.
❑Aquifer Test ❑Stormwater Drainage — _
❑Experimental Technology ['Subsidence Control •
20.DRILLING LOG(attach additional sheets if neckasary)
❑Geothermal(Closed Loop) °Tracer FROM TO DESCRIPTION(color,hardness,sell/reek type,grain sire,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1 ft SD, iL cU111 1Ci1 b r I-
4.Date Well(s)Completed: -iy Well iD# S°� ft. `�uAe • l//��.�p ;, 1 C I�
Sa.Well Location:
J cleft faun if. (Lk t t- I
M -) rLWS ft. CVO- 40 -1 .- - �- .( ,fir i� �7w to rl ft. ft. 0 I tit: . .; 4:a 1,,,'----
,,�— j
Facility/Owner Name Facility IDO(if applicable) !
tt. ft.
11(0 rxlerotor- P rlc_. 1'7r. 1\-AarShd ft. rt. 1 APR t) 2024
Physical Address, I
City,and Zip 21,REMARKS • -
Wtoldism i Il,,.,ic,". ..:4 :4YYRe=a43 l tit,
1
County Parcel Identification No.(PIN) I
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2.Card adon: !
>.
(if well field,one tat/long is sufficient)
ZS' aOLi N R a' 41 11 1 W �.�— , ?,- a -act
Sig ertified Well Contractor I' ( Date
il
6.is(are)the well(s):*Permanent or ❑Temporary
By signing this form.I hereby calif that the well(s)aqs(were)constructed in accordance
with 15.1 NCAC 02C.0100 or 15A NCAC(12C.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 owner.
lfthis is a repair,fill out known well construction information and explain the nature of the
repair under 021 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 plrovide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple infection or non-water supply wells ONLY with the same construction,you can Ii
submit oneform. ( SUBMITTAL INSTUCTIONS ' I
9.Total well depth below land surface: 30S— (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(y20D'and 2@)100') construction to the following:
10.Static water level below top of casing: (,W0 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" ` 1617 Mail Service Center,Raleigh;NC 27699-1617
11.Borehole diameter: ( ` o (in.) 24b.For Infection Wells: In additionIto sending)the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ir o i CUI(1 construction to the following.
(i.e.auger,rotary,cable,direct push,etc.) I
• Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,RalelghI NC 27699-1636
13a Yield(gpm) 4- Method of test U el 24c.For Water Supply&Injection Wells: In adldrtion to sending the form to
the address(es)above, also submit one copy ofithis form within 30 days of
13b.Disinfection type: \Qfl Amount: )ooV1ci1 completion of well construction to the',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

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