GW1--02274_Well Construction - GW1_20240409

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Rex Meadows 14.WATER ZONis
FROM TO DESCRIPTION
Well Contractor Name it. R.
2113-A It. h.
NC Well Contractor Certification Number 1!!C OUTER CASING(tor mdU-eased wolfs)OR LINER prop l!cable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. 1 ft. 1a it. titl In. I pVC
Company Name � /,�/ (� ( Ifs:INNER CASING OR TUBING(geothermal closed:-loop)
2:.Well Construction Permit#: e• D/J1 - V o`T�q FROM TO DIAMETER THICKNESS MATERIAL
• ft. it In.
List all applicable well construction permits(Le.County.State.Variance.etc.) it it In
3.Well Use(check well use): 17 SCREEN I
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. tit In.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. In.
❑industrial/Commercial ❑ esidential Water Supply(shared) III.GROUT
PROM TO MATERIAL EMPPIACEMENT METHOD&AMOUNT
❑irrigation I it2-0 ft.
t a e e i" d ( (U-d
NonaWater Supply Well: tt ft. i
OMonitoring ❑Recovery ft ft.
Injection Well: •
❑Aquifer Recharge ❑Groundwater Remediation V.SAND/GRAVEL PACK(lf appncablc)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
ft ft. 1
❑Aquifer Test ❑Stormwatcr Drainage it ft. 1
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if neccshary)
❑Geothermal(Closed Loop) ❑Tracer FROM i TO i DESCRIPTION(colar,hardness,solUrock type,grain size,etc.)
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) ' D• -12 it atnet
oi- (1XYi-
4.Date Well(s)Completed:)-1pleted1-21 Well ID# 2� `,, ft• ( �' 1l �
3 ft. 3V0 ft. (itr( A ci I
5a.Well Location: Anne-Alcrts C l° ft. it r .ni1.61
navy G.1 Nl kkitivt►'lQN( ft. It.
*'� Faccility/Ow/nerName I� Facility ID#(if applicable) ft. ft. _ , 1
I Mel.,�.�V�, Y(, it It. `�A,."..., e.,r ti l s 'irf ii :: )
Ph steel Address,City,and Zip REMARKS
0...3, 11C' 4'YII 21Al'K a' L024
County Parcel Identification No.(PIN) y
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 'v ti.Y
g Certi lion: ;Cat e i ''
(if well field,one let/long is sufficient)
55' 4 ' '713 N (152,13 l r4( W ' -24
Sig ure f Cettifiedre Contractor Date
6.Is(are)the well(s): Iermanent or ❑Temporary By signing this form.I hereby cell that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0I00 or 1 SA NCAC 02C.0200 Neil Construction Standards and that a
7.Is this a repair to an existing well: DYes or ,,No 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 02l 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
S.Number of wells constructed: construction details. You may also attach additional pages if nenPasary.
For multiple injection or non-water supply wells ONLY with the same construction.you can
submit one form. t 'e SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: ( T `� (IL) 24a. For An Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d((ferent(example-3Q200'and 2(41I00') construction to the following:
10.Static water level below top of casing: t.0 (ft.) I
� Division of Water Quality,Information Processing Unit,
If water level is above casing.use"+^i 1617 Mall Service Center,4Ralelgi NC 27699-1617
11,Borehole diameter: LI" ' s (in.) 24b.For Injection Wells: In addition to sendin the form to the address in 24a
n above, also submit a copy of this form;within 30 days of completion of well
y^r
12.Well construction method: ' v+� construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,;RalelglrI NC 27699-1636
13a.Yield(gpm) 1 v Method of test•. OA 1 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es)above, also submit one copy of'this form within 30 days of
13b.Disinfection type: Amount: 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 i Revised Jan.2013
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