GW1-2021-06870_Well Construction - GW1_20210429

Print Forl,n
WELL CONSTRUCTION RECORD(GW-11 For Intemal Use Only-
1.Well Contractor Information: p
Rex Meadows 14:WA`TONES
Well Contractor Name FROM TO DESCRIM014
2113-A R
NC Well Contractor Certification Number R CASING for.maltl-cased weLLs UR LIlYER"rf"
Clearwater Well Drilling, In0—C
°� �5� oM TO DIAM THICIQiFSS MATERIAL. -
Company Name ((ZT't',O D in' I W
nQ $G* 16 INNERCASING:OR-TQBIIYG. eotheFmildnsed lob
2.Well Construction Permit#: „��SG �� FROM TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits#.e.UIC,County,Stan" 'ance, ic.) R I in
3.Well Use(check well use): tL I 'a Clearwa
Wa Supply Well: 47 SCREEN _
cultural QMunicipaVPublic
FROM TO DiAMEPER.:I SLOTSIZE THICKNESS 'MATERIAL
gri 0 & ;n
Geothermal(Heating/Cooling Supply) 13 Residential Water Supply(single) is
Industrial/Commercial DResidential Water Supply(shared) ;fL
TIrri lion TO MATERIA EMPLACEMENT'METHOD&AMOUNT'Non-Water Supply Well: 1010 fMonitoring Recovery &
Injection Well:
A uifer Rech
q urge Groundwater Remediation GRAVEL PACK ties i bleAquifer Storage and Recovery Salinity Barrier TO MATERIAL EMPLACLiMIIYrMETHODAquifer Test oStormwaterUtainage ft.Experimental Technology Subsidence Control ft
Geothermal(Closed Loop) EJTm= _20:DRUIMGi oG'attaehoddifiomi"ahcuets i(" `
Geothermal eatin C ling Return Other lain under#21 Remarks FROM TO DESCREMON colon tares wWroet er1. <
/p ,t1 & S
4.Date Well(s)Completed: J 1 D 0 Well W# ,
5a.Well Location: : Q�R ZD 'L
2 It U t cr}e
Facility/Otw,nciNaame(� ciGty�iD/#(ifapplicable) % &
tL &
jPhysical(Address,City,and Zip 1L %
•1 1e Vl ,=315 RE11tARKS
Cormty Parcel Idemification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if welt field,one lat/►ong is sufficient) 22.Certificatio
a N _go ►�312.o W
6.Is(are)the wells . ,Permaneut or [Temporary gnau>re fCertifi ell Contractor Date
By signing this fibrin,I hereby certify that!!he well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes orrNor with 15A NCAC 02C.0100 or i5A NCAC 62C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and erplain the nature of the ropy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this fora
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or we]I
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: r�tJ 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd fferent(example-3@200'and 2@100� construction to the following
10.Static water level below top of caging: 110 (fit) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,ry 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter.. -1 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
t1
�( above,also submit one copy of this;form within 30 days of completion of well
12.Well construction method: construction to the following
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY LLLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) Method of test: 24c.For Water Suooly&Iniection Wells: In addition to sending the form to
the addresses) 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 constructed.
f
Form GW-1 North Carolina Department of Favironmental Quality-Division of Water Resources Revised 2-22-2016