GW1--05775_Well Construction - GW1_20240926

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
ft. ft.
Well Contractor Name
2113-A f t. f
t.
15.OUTER CASING(for multi-cased wellsi OR LINER(If applicable)
NC Well Contractor Certification Number PROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. I ft. 44 ft. ( 1 rS In. V C
t6.INNER CASING OR TUBING(geothermal closed-loop)
Company Name FROM TO DIAMETER THICKNESS MATERIAL
_
2.Well Construction Permit 0: 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
__FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
W ter Supply Well: ft. ft. In.
agricultural �Q-t-JM \J„1 e It l ❑Municipal/Public L. —
ft. ft. In.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) _ —
Industrial/Commercial ❑Residential Water Supply(shared) 18 GROUT
❑ FROM TO M�ATE�RIAA�l.I' y EMPLACEMENT METHOD&AMOUNT
❑Irrigation ft. ac-.) ft- �.:U I v�1 l t t I 1i Y\ C-I
Non-Water Supply Well: . I ft, ft.
❑Monitoring ❑Recovery - I
injection Well: ft. It. ,
❑Aquifer Recharge ❑Groundwater Remediation r 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier - ft. ft.
❑Aquifer Test ❑Stonnwater Drainage - ft, ft,
❑Ex erimental Technology ❑Subsidence Control
P26.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer :FROM TO DESCRIPTION(color,hardness,soil/rack type,Crean sire,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 1 it. (I y
n- x)( c4-cji r t
' ..tom ft. LP4C4 n. rat:f1 t fie-
4.Date Well(s) l
Completed: 1 �1Well ID U,I ICI h. UWIL �,r0,A Lk
5a.Well Location: YJC)ft. it ttS R, clrO jm t-}.c.
�0rY) P WU' r' ft. (I
ft. .
Facility/Owner Name Facility iDN(if applicable) ft ft. %�
I0l.D VVl(e tAm c(k ft. rt. SFP 2 0 1974
Physical Address,City,and Zip C�1U e p p i N ��J 21•REMARKS
1�'"11 i-C:h e
I I �IiIJ L
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: �2�Certi ation
(if well field,one lat./long is sufficient) r I
-3 ' 53' Lk-u) 3 N 2,), a155 W -
Sig tune of Certified Well Contractor Date
6.Is(are)the well(s):)ermanent or ❑Temporary By g this form.1 hereby certify that the well(s)was(were)conslntcted in accordance
with 15A NCAC 02C.0100 or 154 NCAC 02C.0200 Well Construction Standard,and that a
7.Is this a repair to an existing well: ❑Yes or copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information a d explain the nature of the
repair-under d21 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
R.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 SUBMITTAL INSTUCTIONS
itthntit one form.
�k'n
9.Total well depth below land surface: -1 1� .) (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For rmdtiple wells nst all depths ifdierent(example-3Ca)200'and 2(na)100') construction to the following:
10.Static water level below top of casing: -1 0 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing.use"+" 1 l.01617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: . (in.)
� 24b.For Infection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of th,s form within 30 days of completion of well
12.Well construction method: (Ur`' 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 2 769 9-1 636
13a.Yield(gpm) I Method of test: i`{ 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Amount: completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Ian.2013

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