GW1--06328_Well Construction - GW1_20241022

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Rex Meadows W.WATER ZONES• I
FROM TO DESCRIPTION
Well Contractor Name ft 8.
2113-A ft. ft.
NC Well Contractor Certification Number _15.OUTER CASING(for multi-cased wells)OR LINER(if ap )(oable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. / n, 35- n• (p/F in. I iavc I
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit ii: 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 I
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
it. ft: I In.
DAgricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) it, ft. In. ,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT I
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation / ft. av EL
P�� a ,Non-Water Supply Well: - I
ft It.
°Monitoring ❑Recovery -
Injection Well: n• ft•
°Aquifer Recharge ❑Groundwater Remediation .19.SAND/GRAVEL PACK(If applicable)
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage ,
R.
❑Experimental Technology ❑Subsidence Control I '
20.DRILLING LOG(attach additional sheets If necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,ILontness,salllrock type,grain sloe,etc.)
°Geothermal(Heating/Cooling Return) []Other(explain under#21 Remarks) / n-t� I. c) `/e Fr
/ ry�[ � ft. n. /a
4.Date Well(s)Completed:t?-! of/Well ID# �� �/�1�4•/p67 ft.a3/7 ft.
5a.Well Locatlo 2/ / ft VO c ll. y3� ve
rhris l '/-e f. R. j , .
Facility/OwnerName�/ /� / ��Facility
�/IDD#(ifopplicabl1e) /]J/ l
9D Gf. //D11,0a)li /' ais Mi/4, ft ft.ft. ft ; ` � ,,,-�i-�~ =n .. :
Physic I Address,CCkity,Ad Zip 21.REMARKS 014 2 ') 2021
County Parcel Identification Na.(PIN) I r r,c,-, u 1 1
22.CoY
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: //tiBcati
�
(if well field,one let/long is sufficient)
3'59-' a 70 N Eo? ` y-y ' o2 b w d/ q-, ,0
signarutu of Certified Well Contractor' ) Date
w 6.Is(are)the ll(s): r ermanent or ❑Temporary By signing this form.I hereby certify that the wells was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200IWell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or J NO copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information an plain the nature of the
repair under 021 remarls section or on the back of this farm. 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.
Far multiple injection or non-water supply wells ONLY with the same construction,you can ,
submit one form. / SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: ' 2 5 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths Vdlerent(example-3Q200'and 2tt)/00') construction to the following: ,
t
10.Static water level below top of casing: (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,use••+•• r 1617 Mail Service Center,Rale gh,NC 27699-1617
1
l I.Borehole diameter: 0 f (in.) 24b.For Injection Wells: In addition to sen ing the form to the address in 24a
�f l above,also submit a copy of thi 7 form within 30 days of completion of well
/
12.Well construction method: /0/0,/1 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) J .
Division of Water Quality,Underground Infection Control Program, '
FOR WATER SUPPLY WELLS ONLY: / � I 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) Method of test: if 24c.For Water Supply&Injection Wells: hi addition to sending the form to ,
/� j� ` �/'J1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: C �ir D/2 Amount: (O o(/l completion of well construction to the coun health department of the county
where constructed.
•
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

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