GW1--04952_Well Construction - GW1_20240816

SC,
WELL CONSTRUCTION RECORD 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. fL
2113-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER Of applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. I ft. Re U fL to I(�-in. v
p n
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop) r
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft• ft. in.
List all applicable well construction permits(i.e.County.State.Variance,etc.) _
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
f4 ft. in.
❑Agricultural ❑Municipal/Public
OGeothermal(Heating/Cooling Supply) *esidential Water Supply(single) ft. ft, in.
0 Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD at AMOUNT
°hrigation I It ao IL Ce.m l4- m t>u d
Non-Water Supply Well:
H. ft.❑Recovery
Injection Well: R. R. —'
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Of applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. It.
❑Aquifer Test ❑Stormwater Drainage
-
ft. IL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soitrock t)pe,grain size,etc.)
OGeothermal(Heating)Cooling Return) ❑Other(explain under#21 Remarks) ( ft. lit 0 R Sat' + r�-
4,Date Well(s)Completed:7 - /Well ID# I 1p() 4� l IQ
Ss*.Well Location: 4t( H. 4(a R. ` U.0 "r
c-Donald 4(a ft. q�sf. c ; u�
Alm Ma
Facility/Owner Name Facility ID#(if applicable) ft. ft. •-• ,
(5S kjh);fe eld La&j Mars Hi' ft. It.
II NC _. . , ..,
Physical Address,City,and Zip / 21.REMARKS f )
County Parcel Identification No.(PIN) !r'�. -:-, 1= i;t `
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Ce 'million:
(if well field,one tat/long is sufficient)
a5' LI-s ' 355 N8' 0g003 W �_____--.-- -a -a4
Si to a of Certified Well Contractor Date
6.Is(are)the we6(s): KPermanent or ❑Temporary this form.I hereby certir that the weft)ass(were)constructed in accordance
with 1 SA NCAC 02C.0100 or/5A NCAC 02C.0300 Well Construction Standards and that a
7.Is this a repair to an existing well: °Yes or 16o copy of this record has been provided to the nell owner.
If this is a repair,Jill out known well construction information and explain the nature of the
repair under#2I 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 injection or non-water supply wells ONLY with the same construction,you can
submit one form. / �( SUBMITTAL INSTUCTIONS
9.Total welt depth below land surface: -7 t/ (ft,) 24a. For AU Wells: Submit this form within 30 days of completion of well
For multiple wells list at/depths if different(example-3fg20`0'and 201100') construction to the following:
10.Static water level below top of casing: (19D (IL) Division of Water Quality,Information Processing Unit,
limiter level is above casing,use"+.. 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ((1 0 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
L above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ro-1-114 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
13a.Yield(gpm) Method of test: 1 1 I"1 24c.For Water Supply&Injection Wells: In addition to sending the form to
� ��jj Q /� 1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:C,1l.�Gn 1 `^ Amount: u[ 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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