GW1--05751_Well Construction - GW1_20240926

WELL CONSTRUCTION RECORD Pnr Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
Rex Meadows r-14 WATER ZONES
FROM ' To INSCRIPTION
Well Contactor Name ft. ft.
2113-A ,,--_ n. ft.
NC Well Contractor Certification Number 1$.OUTER CASING(for ssidco- ed wells)OR LINER Of au
PROM TO DiAMIZTIR THICKNESS MATERIAL
Clearwater Weil Drilling inc. I ft. as ft, i_0.'t ' in. 1
Company Name 16 INNER CASING OR TUBING(Eeothermul dosed-}dap)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit 0: ft. ft. lin.
List all applicable well construction permits(i.e County,State Variance,ele) --
R. fL tn.
3.Well Use(check well use): iT SCREEN
Water Supply Weil: _PROM TO DIAMETER 3LOTSIZE THICKNESS MATERIAL
ft. ft. in,
❑Agricultural o unicipal/Public _ _ )
❑Geothermal Heatin upply( g R, N, in.
( g/Cooling Supp1Y) esidential Wader S sin le)
❑Industrial/Commercial 0 Residential Water Supply(shared) ►.11/*QM"
ItROM TO (�M�ATEyRIIA�L��,,,( £M(P CEMENT METHOD isAMO(1NT
❑Irrigation i R. (0 ft. CC.1 i e. 11 I' ' 1,act
Non-Water Supply Well:
OMonitoring ❑Recovery • ,1
injection Well: ft. ft.
DAquifcr Recharge ❑Groundwater Remediation _19.SAND/GRAVEL PACK Of applicable)
FROM PO MATERIAL EMPLACEMENT METHOD
El Aquifer Storage and Recovery ❑Salinity Barrier n n
❑Aquifer Test ❑Stonnwater Drainage R. R.
OBxpelemental Technology ❑Subsidence Control 4L DRILLING LOG(afaeb adedsolaheets If necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(tailor,baroness,stbrack type,anon else.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under##21 Remarks) ( R' 3 ft' S(Y'k+ nl S r,-
�`� ft. S X1
4.Date Well(e)Completed `�" yWell ID# I^
So./W�eq Location:-{ � �I/ Ca7fUt'lY� 39 S .ft._ C, e�
C Il�� V1 1 i l,iC ft. ft. J . ."4/
r,, —,.
Psrtlity/ erName n ,�I ,:acilityID#(if applicable) I )
V per t .t v e. Rd, 1" ac- ( i KY' R. ► �,,2 i ryt i
Physical Address.City,and Zip P LO`�
21.REMARKS
ct i5o n fi1
County Parcel Identification No.(PiN)
Sb,Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22 Ccr cation•
(if well field,one lot/long is sufficient)
' 9' Ba q N :9 'JJ 5O w ��
Si Certified Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Teegrsrafy By signing thfr Ann,I hereby ces1t'that the well(s)Pas(lure)constructed in accordance
wait/Sd NCAC 02C.0100 or 13A NCAC 0,2C.0200 Well Construction Standards and that a
7.Is this a repair to an existing welt: Dyes or a copy of thte record has been provided to the well owner.
if this is o repair,fill ma known well construction information n plain the nature of the
repair tinder h21 remarks section or on the bock 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
B.Number of wells constructed: construction details, You may also attach additional pages if necessary.
For multiple MMJecllon or non-water supply wells ONLY with the same construction:you can
submit ona form, ,^t SUBMITTAL 1NSTUCTIONS
9.Total well depth below land surface: 3,C (ft,) 24a. For AU Wells: Submit this firm within 30 days of completion of well
Far multiple wells list all depths ifdiffbrant(example-3Qa 200'and 2(4)1000') construction to the following:
10.Static water level below top of casing: LP 0 (ft) Division of Water Quality,Information Processing Unit,
If water level Is above casing,rise"+" 1 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (.10 I (in.) 24b.For Injection Wes: In addition to sending the form to the address in 24a
�U� �Lj above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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: i 1636 Mail Service Center,Raleigh,NC 27699-1636 t
13a.Yield(gpm) Method of teak i`I 24e.For Water Sunk&Inlectleli Wells: En 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 consttucte d.
Form OW-1 North Carolina Department of Environment end Nntersl Resources-Division of Water Quality Revised len.20 I

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