GW1--02260_Well Construction - GW1_20240409

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
I.Well Contractor information:
• Rex Meadows 14.WATER ZONES I ' I
Well Contractor Name FROM TO DESCRIPTtOY i
2113-A IG
NC Well Contractor Certification Number IS.OUTER CASING for multi-cased wells OI LINER f a,.Dcable
Clearwater Well Drilling Inc. FROM iL TO DIAMETERDI METER MATERIAL
Company Name �f _ (� C 16.INNER CASING OR TUBING(• •eot in.
I ,
I�`�21 0 0 SC
I FROM 70 t�1 dosed•!ao
Z.Well Constructiop Permit#: DIAMETER (THICKNESS aATERIAL
List all applicable well construction permits(tie.Count}:State,Variance,etc.) ft' ft. ire
3.Well Use(check well use): ft rt. 1e.
Water Supply Well: 17 SCREEN I
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
OAgricultural L°Municipal/Public fL ft. ia.
OGeothermal(Heating/Cooling Supply) Atesidential Water Supply(single) R. it. In. I
Olndustrial/Commercial ❑Residential Water Supply(shared) 18 GROUT I
['Irrigation FROM TO MATERIAL
I EMPLACES! r�niI4oD&AMouNT
OlniNon-Water Supply Well: I f t. 0 f t. AL�1 1'lX � I 1�.9 (t-I
❑Monitoring ['Recovery ft. ft.
Injection Well: R. ft.
QAquifer Recharge ['Groundwater Remediation 19.SAND/GRAVEL PACK(ifeppliable) I
❑Aquifer Storage and Recovery ❑Salinity BarrierFR
OM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage ft, fw
❑Experimental Technology ['Subsidence Control ft. ft.
['Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets liltecessarv)
FROM TO DESCRIPTION(catot'burdaeA, W OGeothernral(Heating/CoolingReturn) ❑Other(explain under#21Remarks) I R 1S n• tFpaararaaiue[a)
r i-
4.Date Well(s)Completed:c�-1 1 - yell lD# 1 .t01149 R•S/a..Well Location: '-� (01(pfr. �11 fr. anii
UI
l.t�L/ %t 1 1 1L1 ` JLAI iSoc Le 1 V-'ft. -i`t'J ft. n /h to llJp
Facility/Owner Name ft. It. l,ru I( �tl`/t 11•
Facili 1011(ifapplicable) rt.--• .-- �.,
34 'U\O. Ol` )cs QavUvi (LL .,w,P. �;we ia.r w :1
P ical Address,City,and Zip 1 / ft' ft'
✓�-r V U] 1 )1/(i :1.REMARKS �i'A. Cit net
County Parcel ldentification.O.(PIN) fft :-;^ : n7
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Ce 'fication:
3s• y-,3' FAS0 N 8 ' 3` 3Lea w -it -ZL--
Si of Certified Well Contractor Date
6.is(are)the wen(s):)1Permanent or QTemporary
���� By signing this form.I hereby cog,that the wells)sins(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or kNo with ISA MAC 02C.0100 or ISA NCAC 02C.0200 Yell Con/ardor Standards and that a
If this is a repair,fill out blame well construction Information and explain the nature oft a copy of this record has been provided to Clip'uelfarrne�
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 ONLYwitr the same construction,you can
submit onefonn. SUBMITTAL INSTUCt7ONS
9.Total trail depth below land surface: i
go24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijtG,flerent(example-4000'aad 2@l00) construction to the following:
10.Static water level below top of casing: U9 0 (ft.) Division of Water Quality,Information Processing Unit,
Owner level is above casing.rose'"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
]1.Borehole diameter. 4l; I I
Om) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12 Well comstruction method: �'� above,also submit a copy of this form withir,30 days of completion of well
construction to the following; i
(i.e.auger,mtary,cable,direct push,etc.)
Division.of Water Quality,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 MailService Center,Raleigh,NC 27699-1636
lgP ) t Method of test:13a.Yield ai ' I� P.iCI 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above,also submit one copy f this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the i county ealth department of the county
where constructed.
Form OW-I North Carolina deparmento€flnvironment and Natural Resources-Division of Hater Quality
Revised Jan.2013

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