GW1--04905_Well Construction - GW1_20240816

WELL CONSTRUCTION RECORD
This form can he used for single or multiple wells For Internal Use ONLY: I
1.Well Contractor information:
• Rex Meadows 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. R.
2113-A a _.-,
NC Wall Contractor Certification Number IS.OUTER CASING(for multi-cafrd we is OR LINER(II an legible)
FROM I
DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. TO��
1 R• tZ V n '\ in,
Company Name 16.INNER CASING OR TUBING(l )�
l�4- i�'-1 FROM TO et rant claed-1
2.Well Construction Permit#: Duals"EIc THICKNESS MATERIAL
List all applicable well construction permits(i.e.Connry State.Parlance,etc,) ft. R. in.
3.Well Use(cheek well use): ft. R. in,
Water Supply Well: 17.9CR6EN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public R• n. ia.
❑Geotheal(Heating/Cooling Supply) Residential Water Supply(single) R ft. In
rm
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑ltri�ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water SupplyI R• R. /1 1 1 1�
Well: t 1 1 cl )i -�r i
❑Monitoring ORecovery R• R.
Injection Well: R R
OAquifer Recharge ❑Groundwater Rentediation
19.SAND/GRAVEL PACK(if gippllattnla)
❑Aquifer Storage and Recovery ❑Salinity Barrier TO MATERIAL
EMPLACEMENT METHOD
❑Aquifer Test ft. tt.
❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control ft. 1 ft.
20.DRILLING LOG(attach additional sheeta if necessary)
OGeothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM To DESCRIPTION(color,hardn seRtroek
{ypc,Crain she,etc.)
r�-� ft. a� ft. tcC�-I1�� �- rt
4.Date Well(s)Completed:`1-1 t.dLt Well ID# CJs� 1 r(�Xlt ,
ftSa.Well Location: A-11'�i� ic Ca 5 b rri �5 6u' J�' R tG'�J� li
ft. ft.Facility/Owner Name �J t
,,7�AFacility IDN(if applicable)
()C\ 5-0 0 C 6 i O� c Q in. '- R. ft.
—
P(tysical Address, d
City, Zipand \ ,,�t r ( ft. rt. :�j
Co \',i 1(•ri� b '. �v V I I l� l�(y `21.REMARKS
}tf 7 1 ?�24
Unity Parcel identification No.(PiN) —
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: / tSf
(if well field,one tat/long is sufficient) i 2 Cer licatlon:
w I , o
6.Is(are)the well(s): ermanent or ❑Temporary Si 'rare fCenifirxl Welt Contractor Date
By signing this form, 1 hereby cetvjfv that the nell(Si was(were)constructed in accordance
7.is this a repair to an existing well: L1Yes or ( No with Ili NCAC 02C.0100 or 15A NCAC n?C.0200 We/1 Construction Standards and that a
If this is a repair,fill out known well contraction informoth,,,a, explain the nature of the copy of this record has been provided to the well ouv,er.
repair under#21 remarks section or on tire hack ofthL ftnnt.
23.Site diagram or additional well details:
8. of wells constructed: You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
For.Number Infection or Instruct supply wells ONLY with The taint construction,pore car
submit one firm, {({ '/(/��' n SUBMITTAL iNSTUCTIONS
9.Total well depth below land surface: \_t L.l G�
For multiple wells list all depths If different(cram rle-3 00'and 2 Nlo' (ft) 24a. For AR Wells: Submit this form within 30 days of completion of well1 � Ca3 ) construction to the following:
10.Static water level below top of casing: W LJ
(ft.) Division of Water Quality,Information Processing Unit,
limner level is above casing.use ', " ,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: VL 1 J (in•) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Q .11.•t above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: r
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ,/ Method of test: ki C` 24c.For Water SRDDly&infection Wells: (n addition to sanding 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.
Farm OW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality
Revised Jan.2013