GW1--04123_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells I.Well Contractor Information:
14.WATER ZONES
Rex Meadows FROM TO DESCRIPTION
Well Contractor Name H. ft.
2113-A ft. It.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. ( ft if)it. L.Q. il �'in• c�
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
i7 y i FROM
ft. TO DIAMETER _ THICKNESS MATERIAL
2.Well Construction Permit#: Or �J 00 ` IL in.
List all applicable well construction permits(i.e. aunty,State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft_ in.
OAgricultural f11J,/MunicipaUPublic
OGeothermal(Heating/Cooling Supply) gi(Rtsidentiat Water Supply(single) ft. It. in.
❑IndustriaUCornmercial //❑``Residential Water Supply(shared) 1 FROMROUT TO
MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation i R. i'C) �ft. I '
Non-Water Supply Well: � Y'�r
ft. ft.
O Monitoring ❑Recovery ,
Injection Well: It. ft.
OAquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
OAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test OStormwater Drainage
—
ft. ft.
❑Experimental Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets If necessary)
❑Geothermal(Closed Loop) Di-racer FROM TO DESCRIPTION(color,hardness,sall/rak him,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I ft, 1,LQ it S�/1Ai,4 '!, 4- (' l -1
4.Date Well(s)Completed: Weil tD# tL'rt, l 1` rt /ilk( + C� y 1
inn coo!C, CorlS- ruCha) 41 --,--,A ft. 13 f. ( „ jj,l.Q
� 6
5p.Well Location'l 113 ft. `r<� n. /'•,�/1 if
Facility/Owner Name J Facility IDit(if applicable) ft. It. R \ P 3�� , 1
L
5 c �i , ft UL 1 2 102
Physical Ac dress,City,and Zip 23 REMARKS
IY o r IT intEum,ifq.11". ^!oyiv.-11 60,M
County Parcel Identification No.(PiN) DIrt'-:Y' C.s
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.tCerti lion-
(ifwell field,one lat./long is sufficient) r
Signs of ertified Well Contractor Date
6.Is(are)the well(s): P ermanent or OTemporary Br signing this form. 1 herein.cert/f that the well(s)was(were)constructed in accordance
with I SA NCAC 02C.0100 or i5A NCAC'02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or [) o copy of this record has been provided to the'tell corner
If this is a repair,fill out known well construction information and explain the nature of the
repair under#2l remarks section or on the hack 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-water supply wells ONLY with the same construction,you can
submit one form. n SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this fonn within 30 days of completion of well
For multiple wells list all depths if different(example-3`200'andry 2( 100•) construction to the following:
10.Static water level below top of casing: l l( (ft.) Division of Water Quality,information Processing Unit,
If eater level is above casing,use..+" /7 I 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: .Jt ' (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: 1 i
,u (ct 4 above, also submit a copy of this form within 30 days of completion of well
h 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,Raleigh,NC 27699-1636
7 Method of test: * 1(1 24c.For Water Supply&Injection Wells: In addition to sending the form to
13a.Yield(gpm) the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
13b.Disinfection type: Amount:
where constructed.
Form ow-I North Caroline Department of Environment and Natural Resources-Division of Water Quality Revised Jan.1013