GW1-2021-06852_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells 01®
1.Well Contractor Information: 1� 1
�`� 14.WATER ;
Rex Meadows \ ft 7:117
DESCREMON
Well Contractor Name fL 1
2113-A J �' Gessoq fL
NC Well Contractor Certification Number 4 Q gc`i`�0 15.OUTER CASING for maltitased wells)OR LINER K bk
FROM TO DIAMMR THICKNESS MUM
Clearwater Well Drilling, Inc.Hot, , NC 28743 f " R d
Company Name V11 IG JUNMMK SING OR TUBING etosed-loo
FROM TO DIAMETER THICKNESSI MATERIAL
2.Well Construction Permit* fL fL is
List all applicable well permits(1 e.County.State,variance,Injeclion,etc.) in.
ft. ft.
3.Well Use(check well use): t7.SCREEN
Water Supply Well: FROM I TO I DINIIBTER' I SLOTS¢E I TUTfWNESs I MAT Ai.
❑Agricultural DMunicipalt'Pubiic fL ft in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) fL fL tO
1tl GROUT
❑ ustn Commercial DResidential Water Supply(shared) FROM To MATERIAL EMPLACEMENT D&AMouxr
❑Irri lion fL � allon-Water Supply Well: /
fL❑Monitoring ❑Rewvmy ft.
Injection Well: fl fL
❑Aquifer Recharge OGroundwater Remediation 19.SANDIGRAVEL PACK if n lieable
❑ uiferSto FROM TO MATERIAL EMFIACF11tFhrrntSM0D
Aq rage and Recovery OSaI inity Barrier & fL
❑Aquifer Test OStormwater Drainage fc
OExperimental Technology OSubsidence Control
30 DRILLING LOG atlaeb addi6oaal sheets iY
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPnON color tnedaa,,sorW.k ahz.ere.
❑Geothermal(Heating/Cooling Return) ❑Other lain under 021 Remarks) R R yj
4.Date Well(s)Completed: i s t9welllo R fc �
fL fL
Sa.Well Location: 3 `,�,
� n = Gf ft. R
Facility/Owner Name �y/ Facility MP(ifapplicable) / ft fL
A T?`-410A, c � IsIVs�� fL fL
Physical Address,City,and-tip
31 REMARKS -'
Comuy Parcel Identification No.(PIN)
5b.Latitude and Longitude in degreeslminutes/seconds or decimal degrees: 22.Certification:
(if well field,one Wang is sufficient)
Sigfiaturc qfCertificd Well Contractor Date
6.Is(are)the well(s): er-anent or OTemporary By signing this form,I hereby cert6 that the wells)was(mere)constructed in accordance� with 15A 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 —'"_ copy of this record has been provided to the well owner.
Ifthis is a repair,fill out brown well eonsinxton information and explain the nature ofthe
repair under f21 remarks section or on the back of thisform. 23.Site diagram or additional well details:
&Number of wells constructed You may use the back of this page do provide additional well site details or well
construction details. You may also attach additional pages if necessary.
For multple injection or non-water supply wells ONLY with the sane eo_w7"otion,you can
submit one form y�y9[ SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: i'1 J (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(crumple-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. i (in.) 24b.For Infection Wells ONLY: 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: ' �� Irk, construction to the following_
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
E13b.
WATER SUPPLY11 ONLY: t} 1636 Mail Service Center,Raleigh,NC 27699-1636
Yield(gpm) �9 Method of test l i.'`�7 24�For Water Supply&Injection Wells:
Also submit one copy of this form I within 30 days of completion of
Disinfection type: Amount: well construction to the county health departrnent of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013