GW1--02139_Well Construction - GW1_20240409

WELL CONSTRUCTION RECORD
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For Internal Use ONLY: I
This form can be used for single or multiple wells
1.Well Contractor Information:
Rex Meadows 14.WATER ZONES I 'r I
FROM TO DESCRIPTION
Well Contractor Name ft. ft. I I
21 13 A ft. ft. III
NC Well Contractor Certification Number 15.OUTER CASING(for-multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER I! THICKNESS MATERIAL
Clearwater Well Drilling Inc. I pt. - fL 1121�j 1 In. I p ve
Company Name "16.INNER CASING ORTUBiNG(geothermal diked-loop)
FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: ft' ft. I:iu.
List all applicable well construction permits(i.e.County,State.Variance,etc) ft. l
It. in.
3.Well Use(check well use): 17.SCREEN . . - I I I
Water Supply Well: - FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ❑MunicipallPublic it ft. in'
❑
OGeothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. R. In. I
❑lndustriaYCommemial ❑Residential Water Supply(shared) 1S CROUT
FROM TOOf'� •
MATERIAL' I: EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: I ft.
SXV eQ ER e`` nt tf\411 t
�1
fL ft. ' I I
❑Monitoring ❑Recovery
Injection Well: ft. It. ! I I
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(ifapplfc6ble) - I
FROM TO MATERIAL', I' I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. R. II I
❑Aquifer Test ❑Stormwater Drainage '
°Experimental Technology ❑Subsidence Control fl
20.DRILLING LOG{attach additional shcetsIf necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,solllroek type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1 ft. 39- ft. rc!E p� c a
_ 4.Date Well(s)Completed:''01-9'I Well # � B. 5`Qlnft, 1l J� ��%y�R I
5a.Well Location: aD �C�AJP�0 011'l G �Q ft. 5 fl rt. t
5ac"1 f 1Qn ft rI a,t/l.I
Ke nr\P .4- \1 e-rcn►vet ►ea-n ft. ft. J I I
Facility/OwnerName Facility ID#(if plicable)
1 q 0 Rvei Glens Dr. VVeaver ft. rt. . \ t...+°a... ,al ",1 ii
Physical Address,City,and Zip C 21.REMARKS . I ^+"R '3 [G Z4
�1C'a,lOn I "
County Parcel identification No.(PIN) liliJ:m I'..1 'r:;. ;r tINAI
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2 . e lineation: t`}�d("'3v+�
(if well field,d,one lat/long is sufficient) (� C1 t
35' I N..y'is N g r `i O T o 1 W S -a--i ay
Si cure of Certified Well Contractor j• I Date
6.IS(are)the well(s): Permanent or ❑Temporary B si this form.I hereby certify that the nell(s)was(were)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: [Wes or .�No copy ofthis record has been provided to the will gamer.
If this is a►epoir,fill out knout well construction information and erp►ain the nature of the ' I
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,you can
submit one form. SUBMITTAL INSTUCTIONS I.
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9.Total well depth below land surface: Le o I(it) 24a. For All Wells: Submit this form with 30 days of completion of well
For multiple wells list all depths ifdi erent(example-3@a 200'and 2C1100') construction to the following: l' I!
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10.Static water level below top of casing: Q (ft.) Division of Water Quality,Information Processing Unit,
((water level is above casing,use"+" R` 1617 Mail Service Center;Ral h,NC 27699-1617
Il.Borehole diameter: " (in.) 24b.For Infection Wells: In addition to sensing the form to the address in 24a
above,also submit a copy of this form withm 30 days of completion of well
12.Well construction method: \U31 a•'v1"t construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) ,' 1
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center;Raleigh,NC 27699-1636
I' I.13a.Yield(gpm) 5 Method of test: l 24c.For Water Supply&Injection Wells: addition to sending the form to
q '^ the address(es)above, also submit one'copy this form within 30 days of
13b.Disinfection type:Chk 0`1 � Amount: c V ne 5 completion of well construction to the county health department of the county
where constructed. l I
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Form OW-I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013
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INS MOW Saill4hrout Cordficailon
ra_ wen:
oweLiadd—k—.
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Permit K)/CA/tfAA it(
'herby way that ibe above%damned weR was grouted in appearance in acaadanamkb.
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C.erdficate#: /1 3 -4
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Dlanaeer fi
Height
Drive Shoe:
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