GW1--05850_Well Construction - GW1_20241001

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 ft. ft.
2113-A ft. rt.
NC Well Contractor Certification Number 13;OUTER CASING(for muttl-cued.well.)OR LINER Of
PROM ' TO DIAMETER THICKNESS MA
Clearwater Well Drilling Inc. i ft. ' - ft. CD'I jtp• PU C-
Company Name �16.1NNER CASING OR TUBING(anathemas'dosed-loop)
`� `- FROM TO DIAMETER THICKNESS _ MATERIAL
2.Well Construction Permit#: \ J 1 R. ft M•
Lau all applicable well construction permits(i.e.Counry,State,Variance,etc.)
—
Ti. ft. tn.
3.Well Use(check well use): i7 SCREEN —
Water Supply Well: FROM TO ' DIAMETER SLOT�'SIZE THICKNESS MATERIAL
ft. FL in.
0Agricultural °Municipal/Public _.
❑Oeothermat(Heating/Cooling Supply) Residential Water Supply(single) It• U. —
In.
❑Indnstria1/Commercial ❑Residential Water Supply(shared) -18•GROUT
PROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation I R, t9 D p, ,fit n - t p1 i- �i !/
Nen-Water Supply Well: - R. V ft.
l�c 1 I i lei V V
❑Monitoring ❑Recovery --. .
injection Well: ft. ft.
❑Aquifer Recharge DGroundwater Remediation A9.SAND/GRAVEL PACK Of IlpW1IC !)
(]Aquifer Storage and Recovery C(Salinity Barrier PROM TO MATERIAL EMPLACEMENT martian
U. ft.
0 Aquifer Test DStormwatcr Drainage ft. ft.
❑Ezperitnrrutal Teeilnologs ❑Subsidence Control U.DRILLING LOGtalloeYadillNalsleets If aeceatary)
°Geothermal(Closed Loop) C1Trecer PROM TO DMIORIPTION eelor harden,aalttrachtype,grataUse,etc.)
OOeothermal(Heating/Cooling Return) ClOther(explain under#21 Remarks) t�1 O. 1l.L n- s ue) 4—, (1 ( i i
ttspletedt U We
..as i, 4- ft• l i J t ,
4.Date Well(e)Co ~
Wen Location: 5� 51 C U --t
IN Lion: c -� rt. LOOS"n. •i�,
M o _,s► not 5' R. ff. "� ►-e i 1. this
Facility/OwnerName Facility'q&(ifapplicable) J
IO5 ';ObCI I CLUQf l � 1� )YfS Al ft. ft. .
Physical Addiess,City,and Zip 21.REMARKS
i 1 C ^ '�..d Parcel identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutesiseconds or decimal degrees: 22. a,
(if well field,one lat'long is sufficient) 5
' 905 N r 1 ( J U W -'N.------------ S =2 l - L .
Si 9featified Well Contractor Date
6.Is(are)the well(s):)Permanent or UTenlperary By signing Mk form.!!tenth),cerrtf)+that the well(s)was(Isere)eoretn•ucted in accordance
with ISA NCI 02C.0100 or ISA NCAC 02C.0200 Well Constriction Standards and that a
7.1s this a repair to an existing well: ❑Yes or EYo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the beck 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
sulnn)t one form, SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (bS_ (It) Z4*. For All Wells: Submit this fcrrrn within 30 days of completion of well
For multiple wells list all depths 1fdifferent(example-3®200'and 2(,1o0') construction to the following:
10.Static water level below top of casing: l.11 0 (ft.) Division of Water Quality,Information Processing Unit,
If*vier level is-above casing.use..+`I 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ILO 1 (IR.) 24b.For Inlection Welly In addition to sending the form to the address in 24a
�,r �/y �� above. also submit a copy of this farm within 30 days of completion of well
12.Well construction method: 1 O I C.1/CY-.i construction to the following:
(i.e.auger,rotary,cable,direct push,ate.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a
1 i C 24e.For Water Swarth'Swarth'&lnleetion Wells; in addition to sending the form to
Yield(gpm) Method of test: the address(es)above, also submit one copy of this form within 30 days of
13b,Disinfection type: Amountarmpktion of well construction to chic county health department of the county
where constttrcted.
Form OW-1 North Carolina Department of Environmerx and Natural Resources—Division of Water Quality Revised Jan.2013

WS.DOW WIifirout C
ov:2 ordaseden
/ 29
Addrese l
Permit /D/
*telly the above referenced well was grouted in appearance In acioatlancewith
all CauntrAtit ndea
weii --x skv,edt
cadocatec a// - _ Deriec�rok
Ganes: ( eau
Casing * Tttlnrees•
Casing _ ,
n t 7E
Divechrwr
GPM /