GW1--06327_Well Construction - GW1_20241022

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WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells Far Internal Use ONLY:
1.Well Contractor Information:
Rex Meadows 14.WATER ZONEES ' i
FROM TO DESCRIPTION I
Well Contractor Name ft. ft 4
2113-A rt. R. " I I
NC Well Contractor Certification Number 'S:OUTER.CASING(for mnlft-need wells)OR I lNER Of lip e)
FROM TO , DIAMETER THICKNESS MATERIAL
Clearwater Weil Drilling Inc. / R. 5L f. ft, , /j /5 in. , I /)V 2
Company Name 0 Id.INNER CASING OR TIMING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: H, ft. in. I
List all applicable well constnretion permits(i.e Cminry,State,Variance,etc.)
tl. R. In.
3.Well Use(check well use): 17.SCREEN I
Water Supply Well: PROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural ClMunicipal/Public H. ft la I
OGeothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. R. In.
❑lndustrial/Commercial ❑Residential Water Supply(shared) h'IoGROUT TO MATERIAL�eMJATE/hRiAL EMPLACEMENT METHOD&AMOUNIT
❑irrigation / it' q�(/ B' ` f Pmaiod
Non-Water Supply Well:
❑Monitoring ❑Reco fa ft.
injection Well: Y R. rt.
❑Aquifer Recharge ❑Groundwater Remediation A9.SAND/GRAVEL PACK(If RPIllcable) I •
°Aquifer Storage and Recovery ❑Salinity Barrier FROM t TO MATERIAL I EMPLACEMENT maroon
ft. ft. I
❑Aquifer Test ❑Stomtwater Drainage -
❑Experimental Technology ❑Subsidence Control R. H.
2o.DRILLING LOG(attach additional sheets If necessary)
❑Geothermal(Closed Loop) ❑Tracer _ FROM i 7o -( DESCRIPTION(Wan!melon,sell/reek typo,amain elu,de.)
°Geothermal(Heating/Coolingng Return) (�❑Other(explain under#21 Remarks) / IL JET ft' t�� N .Cfl' 1�[ifs-F .
4.Date Weil(s)Completed:% 5 t2 t Well ID# • J D• /( f ft. �� �le
,
S .Well Location: Kiln/ ft ee'L`+ ft.
t �/d, I .-
• L�C�rYi �i��G i ) ��s R. � �e1
Facility/Own1ame Facility 1D#(ifapplicable) r D• ft T ' �
(�V ft�7) eel a w/ L > .....
ft. R. " .,"4 s•� �_.�
Physical AdtbeM.City,and Zip /1446V3h`� �P e 21.REMARKS (III
! % Lf74
County Parcel Identification No.(PIN) -- •.:•--.•: ;-� _,�,g :;:!As
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,cad / n:
(if well field,one lat/lang is sufficient) r
"e�on! •50n 8- N Sa 35 r5 (a W p - _
Signetum of ied Wolf Contractor I Date
6.is(are)the well(n): -•Permanent or ❑Temporary
By signing this form,7 hereby certify that the wells)was(WOW aansavcled N accordance
with ISA NCAC 02C.0100 orISANCAC 02C.0200 Well Constnrcr/on Standards and that a
7.is this a repair to an existing well: Ryes or I1No copy of this record has been provided Nthe well owner.
Mitts is a repair,fill oar known well construction information a d explain the nature of the
repair wider 021 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional wall site details or well
B.Number of wells constructed: construction details. You may also attach additional pages if necessary. •
FM'Multiple infection or•non-water supply wells ONLY with the sameConstrnedon,you can
su/irnil one form, 1�J J,. SURMtrrAL iNSTUC TIONS
O.Total well depth below land surface: /(fi'r J (IL) 7rIa. For All Wells; Submit this form within 30 days of completion of well
For multiple wells list all depths ifdfjjhranr(example-30a 200•and 2(9100) construction to the following:
10.Static water level below top of casing: 0 (ft.) DIviSion of Water Quality,Information Processing Unit,
If tearer level is above casing,use•''+" i 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 40 (in.) 24b Per Infection Well* In addition to sending the form to the address in 24a
above,also submit a copy of this form within 30 days of completion of well
12.Well construction method: rl fQ.gi construction to the following:
(i.e.auger,rotary,cable,direct push,eta)
Dtvlsion of Water Quality,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: gei 1636 Mail Service Center,Raleigit,NC 27699-1636
13a Yield(pm) a Method of test: 24e.For Water Supply&Inleet[on'Wellg: in al dition 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 1'ealth department of the county
where constructed.
Form OW-I North Carolina Department of Environment and Natural Resources—Division of Weterguality Revised Jan.2013
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thereby cest*that the above rammed well vas grouted ta ,' fnaccordanceviith
all CountyWOR rules. 1
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. Ibtel Depth; 7&.5—
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