GW1--04956_Well Construction - GW1_20240816

WELL CONSTRUCTION RECORD
This form can he Sued for single or multiple wells f For Internal Use ONLY:
I.Well Contractor Information: f4t
Rex Meadows 14,WATER ZONES
Weil Contractor Name FROM TO DESCRIPTION
ft. ft,
2113-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-ailed wells)OR LINER(if apnlieoble)
FROM
Clearwater Well Drilling Inc. DIAMETER THICKNESS _ MATERIAL
1 ft. :3 it (�'I c In
Company Name ��u-C,
16.INNER CASING OR TUBING(geothermal d -loot _
2.Wen Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.Counry.State.Variance,etc.) ft' ft. in.
3.Well Use(check well use): rt. an.
Water Supply Weil: I7.9CRhEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft• rt. in.
°Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft rt. fa.
❑lnduatrial/Commernial ❑Residential Water Su IS.GROUT
pp.1y(shared)
most
MATERIAL EMPLACEMENT METHOD&AMOUNT i
Non-Water Supply Well: ft.
allR' CCri
❑Monitoring rt. tr. � ` `��❑Recovery
Injection Well:
H. o.
(JAquifer Recharge ❑Groundwater Remtediation
I9.SAND/GRAVEL,PACK if .. eEft�
❑Aquifer Storage and Recovery ❑Salinity Barrier mom TO r{ATggf�— -----
EMPLACEMENT METHOD
OAquifer Test ❑Stonnwater Drainage ft. ft.
❑Experimental Technology °Subsidence Control ft' ft'
I
20.DRILLING LOG(attach additional sheets If necessary)
❑Geothermral(Closed Loop) OTracer
-
QGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) PROM ft' To ft' tDESCRIPTION(calory hardness,sWthnep
type,grain ataxy etc.)
SS � 11/4-1--X:k. `'fr iCk4 fi -}--
4.Date Well(s)Completed:9- CI-a ywell ID# SS ft. 11lP ft. () rark,i-�
Sn.Well Location: „kQ ft. ��1 ft. (t_�a(,( .
Facility/Owner Name ft.
Facility ID#(if applicable)
It. R. •a�,.
u I I t f -1u 1
Physical Addresss City,,nd Zip ft. ft. AUG
\,lC,Rrt�S)�J�� 21.REMARKS 2024 '
County �1 Parcel identification No.(PiN) Ire: L1_
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:(if well field,one Iatilong is sufficient)
fficient) P .Cer anew:
3 � 'o2vci N S 3S 3GS- w 1
6.Is(are)the well e; �p Si hue of Certified Welt Contractor --'
ermanent or ❑Temporary Dare
()
By s Mg this form, I hereby certh5.that the well(s)war(were)constructed in accordance
7.is this a repair to an existing well: ❑Yes Orpk
p with ISA NCAC 01C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
If this isa r eppa/r,fill out knownwell construction information rend explain the nature of the copy op his record has been provided to the hell ounce
repair under 101 remarks section or on the hack of this knm.
23.Site diagram or additional well details:
S.Number of wens constructed: You may use the back of this page to provide additional well site details or well
Ern•n...L:t,L,;;%«,h,.,or,ran-water supplyennetn,e6oe detail°, You may also a+iacti aciChn sal pages if necessary,
wells ONLY with the UM roottreefiog you can
submit one Arm. I J S_UBMi7TAL INSTUCTIONS
9.Total well depth below land surface: l 6
For muhipte welts I/st all depths ifdltrerent(example-3(4)200'and S 1 (ft.) )tc All Wells: Submit this °ran within 30 days of completion of well
dII�� ��7 construction to the following:
10.Static water level below top of casing: ._QV
I/abler level is°have case (ft)) Division of Water Quality,information Processing Unit,
tug,usel'�+" 1617 Mail Service Center,Raleigh,NC 27699-1617
`
11.Borehole diameter: l 0 f O (i•,) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: r[5 � ,( above, also submit a copy of this form within 30 days of completion of welt
(i.e.auger,rotary,cable,direct posh.etc.)
__''`t etion 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) a J Method of test: R 24c.For Water Simply&infection a 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 1 "� Amonsib `G completion of well construction to the county health department of the county
where constructed.
Form
OW-i North Carolina Depanmenr of Environment and Natural Resources-Division of Water Quality Revised tan.2013

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