GW1--05776_Well Construction - GW1_20240926

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Rex Meadows 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name R. ft,
2113-A ft. ft.
NC Well Contractor Certification Number —IS.OUTERCASING(tor maul cued wells)OR LINER(If an )
PROM TO DIAMET6A THICKNESS MATIfRLAL
Clearwater Well Drilling Inc. 1 R. 5(4. R. LO 1 )in. p
Company Name 16.INNER CASING OR TUBING(geothermal Hosed-loop)
2.Well Construction Permit#: V(
),_(6-2.
� t f�( l/] FROM
ft. TO
rt. DIAMETER THICKNESS MATERIAL
In-.
List all applicable well constntctiou permits(i.e.Canary,State, Variance,etc,) fl In —'
3.Well Use(check well use): 17 SCRREN
Water Supply Well: :FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. R. in.
❑Agricultural ❑Municipal/Public _ )
°Geothermal(Heating/Cooling Supply) Oesidential Water Supply(single) a, rt. In.
DlndustriallCommercial ❑Resident ial Water Supply(shared) �18-GROIJT
PROM TO ATaRIAL EMPLACEMENT METROS&AMOUNT
Irrigation ) ft. ',?'i R. r/n i p•d
Non-Water Supply Well: 1 1 1 L
0 Monitoring ❑Recovery ._ ft. I _ --t
Injection Well: ft. ft.
°Aquifer Recharge ❑Groundwater Remediation JI9.SAND/GRAVEL PACK(If gggoable)
PROM TO MATERIAl. EMPLACEMENT METHOD
°Aquifer Storage and Recovery °Salinity Barrier [t O
❑Aquifer Test DStomiwater Drainage - —
ft, ft.
❑izperimental Technology ❑Subsidence Control M.DRILLING LOG(attach additional sheets It necessary)
°Geothermal(Closed Loop) OTracet PROM TO DiSCRI taro rttrrsca type,grain tile,me.)
°Geothermal(Heating/Cooling Return) °Other(explain under 621 Remarks) I R- 3 R. t�c17cTe' r
ii ft• 0 Ilk iretARA, -c
4.Date Well(a)Coltspleted: Well IN
Ss. ell Loudon: 1ft. feu cie.
• 34-S R•
r
ft.
Ciac
Facility/Owner Name flit (if licable)
al0-75 }�1A ,l lv 1 �), z' .) 1,4 ft. ,. -
Ph l Address City,and Zip '
yaiMi k-dv.,,l I n.w,►>llns CEP 2 (; 20Z4
County Parcel Identification No.(PIN) J_ f'. :•
Ifai:7fd..
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: C
Of well field,one Istllong is sufficient}
9
. , -,t1 I - (.f' d ' 901 , ct 410 w A....xl-, . .
Si ofCeRified all Contraotor Date
6.Is(are)the well(s):)Permanent or OTemporary gy form.I hereby eertg that the wefl(s)was(ware)consn•ucted to accordance
with 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: Dyes or o copy of this record has been provided to th.e well owner.
lfthts is a repair,fill out known welt consnvetton Irtfbr,narlon and erpinin the nature nfthe
repair under#21 remarks section or on the back ofthis.jor•m. 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
sn/an/i one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: .4r...) (IL) 24a. for All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths if d(Qercnt(exempla-3Q200'end 2®1001 construction to the following:
10.Static water level below top of casing: (19 0 (ft.) Division of Water Quality,Information Processing Unit,
limiter level is above casing,use"+" i I 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: `S' (im.) 24b.For lniectton Wcjlg: In addition to sending the fo:io to the address in 24a
1 above, also submit a copy of this form within 36 days of completion of well
r
12.Well construction method: 1 C)t IN 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 Mau Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of test: t Ci 24c.for Water Sitpoh•&Infection Wells: 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: Amount completion of well construction to the county health department of the county
where constrained.
Form OW-I North Carolina Department of Environment and Nnteral Resources-Division of Water Quality Revised Jan.20:3

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