GW1--03207_Well Construction - GW1_20240524

VY LLL UIJLS 1 KU l:1!UN KLI:UKU For internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
• Rex Meadows 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft ft.
2113-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING((or multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling inc. ft. yo ft.' LQ 1 in, )Ulm
Company Name rrll 16.INNER CASINO OR TUBING(I exo m theral dosed-loop)
2.Well Construction Permit it: c Dc 3- 003o 3 FROM ft TO ft DIAMETER to THICKNESS MATERIAL
List all applicable well construction permits(i.e.County.State.Variance,etc.) _
rt. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER. SLOT SIZE THICKNESS - MATERIAL
ft. ft. in.
❑Agricultural OMunicipal/public
OGeothermal(Heating/Cooling Supply) *esidential Water Supply(single) ft tt. in�
❑Industrial/Coimnerciai ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: n. 9�) ft. 11�f�(ti/�1� ,(V1 N ) j1
ft. ft. l 1 t 1'S 1 t I t 1 1 WI U
OMonitoring ORecovery
Injection Well: ft. ft.
❑Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK(if applkable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier ft- ft.
DAquifer Test OStormwater Drainage ft. it.
OExperimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hurdoas,soli/rock type Rhin size.etc)
DGeothetmal(Heating/Cooling Return) OOther(explain under#21 Remarks) ft. ft. t ' ("y ) .d / (r til
,y ' �� ft. ' 91�Q1 p \ t 4.Date Well(s)Completed: `�-J Well ID# 5�
5a.Well Location: 510 ft. 5-1 1 f t. I;,."Vi U.,
M 1.4Y,( 11 ft.
.GS ft. q69._ni
1 1 1 JVI� .� �h�(1� ft. ft.
Facility'Owner Name Facility 1D#(if applicable)
ft. ft.
-15 1,44-n . MO cinoliCC Dry Lcice--- r ft. ft.
P`h ical Address,City,and Zip
->') N C., KS 21.REMAR r� •
County Parcel Identification No.(PiN) h Y '! g
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: t22 e 'nation:
(if well field,one laulong is sufficient)
If.: r: :4:..
-3 ` au. LL 0 N d. 4 '4 73 O w -- 'c .� c: -C
Si ure�of Certified Well Contractor Date
6.Is(are)the well(s): ermanent or OTemporery By signing this form. 1 hereby certify that the%wilts)ins(nere)cartsrruc-tecl in accordance
with 15d NCAC 02C.0100 or ISA NC,IC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: UYes or o copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and plain the nature of the
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 Dejection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTiONS
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple taros list all depths if d erent(example-3 a100'and 7@!O01 construction to the following:
10.Static water level below top of casing: to (ft.) Division of Water Quality,information Processing Unit,
If water level is abuse casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
4 above, also submit a copy of this form within 30 days of completion of well
ri`
12.Well construction method: l 1 LXJIlA 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,Raleigh,NC 27699-1636
(gpm) EL 1 J 13a.YieldMethod of test:_R--• c 24c.For Water Supply&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 City-I North Carolina Department of Environment and Natural Resources—Division or Water Quality Revised Jan.2013