GW1--03200_Well Construction - GW1_20240524

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 ZONES I
FROM TO DESCRIPTION
Well Contractor Name • ft. ft.
2113-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if apeNesbit)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. 1 ft. Weft. le.17 r in. ,-),
_,..
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
�V � MOOS
FROM TO DIAMETER THICKNESS 5ATERIAL
r 2.Well Construction Permit#: M rt. ft. in.
List all applicable well construction permits(i.e.Country.State.Variance,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAAIFTFR SLOT SIZE THICKNESS MATERIAL
R. ft. in❑A ricutural DMunicipal/Public ^
❑Geotheal(Heating/Cooling Supply) Kiesidential Water Supply(single) H ft. In.
rm
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL— iMPLACHMEPI1'METHOD&AMOUNt
❑Irrigation
Non-Water Supply Well: -1 it :-)uit. (i-'/)i'j)f a
❑Monitoring ❑Recov�Y ft. It.
Injection Well: H. ft. 1
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(If applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO f 1ATERLtL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
R. R.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets If necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(star,hardness,soil/rock type,grata stn.,etc
)
❑Geothermal(Heating/Cooling II'
(� ❑Other(explain under 421 Remarks) / ft• ( fftt• L .j,8)47 pry/per,/,f,J
4.Date Well(s)Completed: II-1 -&VV tell l Dot `� � �"" �t f�f f/I T C� -
1 ft. '357 ft,
5a.Well Location: AlaW/'1 /'IQ•A.Jer) I,
t�OrWik r) St Tam; F/ ft. `f ft. qqa.90
s_~"
Facility/OtvnerName Facility ION(if applicable) T. ._ r,4 p„...
11.1
ft. ft.
t etddidia d- Qr. ft. ft. 1 MAY 2 2024
Phys 1 Address,City,and Zip 21.REMARKS
�(IO1�l}, " 'i!Unit
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient) 22 Lion:
Si tore of Certified ell Co r Date
6.Is(are)the well(s): Kmanent or ❑Temporary By signing this fore.I hereby cerlj/l that the me0(sl iIms(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 o copy of this record has been provided to the well ounce.
!lifts is a repair,fill out krona well construction information explain the nature of the
repair under#21 remarks section or on the bock 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 necessary.
For multiple injection or non-enter style wells ONLY with the same construction,vu,,con
submit one fora. SUBMITTAL iNSTUCTIONS
l
9.Total well depth below land surface: S (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple urns list all depths if different(trample-Sly 200'and 20,61001 construction to the following:
10.Static water level below top of casing: 0 (ft,) Division of Water Quality,information Processing Unit,
[limier level is above casing,use' " 1617 Mail Service Center,Raleigh,NC 27699-1617
/�� / G
II.Borehole diameter: Cf.i t7 (Sa) 24b.For Injection Wells: In addition to 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: tb0i 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: /Jn/� 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
/13a.Yield(gpm) L? Method of test: /E le7 24c.For Water Suably&Injection 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 Revised Jan.2013

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