GW1--04144_Well Construction - GW1_20230623

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 - i
FROM TO DESCRIPTION
Well Contractor Name IL fL
2113-A m ft,
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS I MATERIAL
Clearwater Well Drilling Inc. { fL C91 ft. (Q to in. I I �l'^\c_,
CompanyName -16.INNER CASING OR TUBING(geothermalIdosed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. fL la. I
List all applicable well construction permits(i.e.County.State.Variance.etc.)
ft. fL is I
3.Well Use(check well use): 17.SCREEN {
Water Supply Well: • FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. In.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) R. ft. In.
)
❑industrial/Commercial °Residential Water Supply(shared) 18.GROUT I
FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
❑Irrigation L ft- n. : �eht I m i
Non-Water Supply Well: ILO
❑Monitoring ❑Recovery
n. ft I
Injection Well: • ft. rt.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) II
Cl Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I "EMPLACEMENTMMETHOD
n. fL I
❑Aquifer Test ❑Stomiwater Drainage
❑Experimental Technology ❑Subsidence Control n f t.
❑Ge°themlai(Closed Loop) ❑Tracer 28.DRILLING LOG(attach additional sheets iflnecessery)
FROM TO DESCRIPT ION tcotor/.hardness.saiUrocktine. -sire tic
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) i tt: d9-1 n:
5-7,5 al fr. ft. r0X11-16
4.Date Well(s)Campt>?icd. �"'��'ett iDtr �!��R, j� n' �� I
Mttt���5�.�//W��jciltYLocatiopnit:� C �lL� fL 4\4lt� ft. ���, }�•�+ ,C
f/v K A Debra Ot(\ vox - I l -D /��g_,�a A Tr R�r..'..
ft, ft. 6 p:��.J t.,.i V ..^.t,,..
Facility/Owner Name (/�/y` �►�/1t Faciil_ityy IDSSJ(if appliica(ble) R. I t1
.eel _ , + ' /��s, V`L t ,v c ft n. I.�l ` �11��
Physicali Address,City, d Zip L 21.REMARKS
4Ork O f ttaso +DWQIt.�..11 l.+ti:
County Parcel identification No.(PIN) '•y j`
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 •rEiticafion:
(if well field,one tat/long is sufficient)
35' 5is. 12D N 2 -1- 4a s��d ,, 5 as- 23
Si ore of Certified Well Contractor Date
6.Is(are)the well(s):Aernintsent or ❑Temporary By signing this faun,I hereby cer1ifr that the lelI()was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0201 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or No copy aphis record has been provided to the well own-T.
If this is a repair,fill ma known well construction Information and erpiain the nature q/the
repair under 112/remarks section Gran the back of thisform. 23.Site diagram or additional well details:
• -: _�. •:fL�r.__.:_3 .... _ .!` ._.... ...�3_:rT..: nl:�' rf: ____- __
8.Number of wells constructed: construction details. You may also attach addi lona!pages if ncees_sarr.
For multiple injection or non-water supply wells ONLY with the same constraction.you inn
submit one farm.
SUBMI 7AL INSTUCITONS
.. ._..., •v,aA%e._•r- r_••= 'vs 1 �� �:: ... .- n-. ...... :z:.r :r:,< r=.-:: r r:_ it?dtr.. -al.. -...e._Par'magpie wells list all depths Irdif hrent(crorplc•3^m2u3•and 2CI00') Constitution to the following: 1-:::!:
y r
10.Static water level below top releasing: (ft.) Division of Water Quality,Information Processing Unit,
If m .?moor lova rr ohm. n_..t.y.1 lOn Q z•• 1c17 ryt,n__ .44 _--_ -
II.Borehole diameter: ,1`' (in.) lob.For Injection Wells: in;addition to sending the torte to the+address in 24.E
M con:r tiu t'tt a fol•3� - .,.... a .... of
'WW, npy at'T form w1 tin 3DDD days completion of well
12,Welt construction method: eonstructi°n to the following:
utvssson of Water;,luality,Underground injection Control Program,
I MR.fiA1-Til S.t'`Al X i ST t E dNi-y: ..•....—? t(x 4`.,:1 Snr3^c___r'_r.=_j : n n 2?!.'::".:-:::::::
aL 24e.Fox Wae4slp itriecIj u Wells: l�addition t:crtiiag::se g-.rm rn
•4 13a.Yield f_�7:t k4orK
.mout= I completion.of well�A' r ctiUS torie count jhealth acSe:TSCR o tC county ilt1136.Jsinfeetion type: P _

Waft Driller Self-Snit Certification
McLr L d' 0ebrc�.
Owner Q A,UU.►\19-11.1 New Well: I�
, $ flL 4 Ca ►ir: .
I i'Ao sryt ivC
I beip.by certify that the above referenced well was grouted in appearance in am with
all cotmty Well rules.
Well Dam 2 )e--)( Me0dOWS
r caIe#: DateGrouted:55 3
consIru Grout:
Total Depth; _4 Type; __
Casing TYPel pv. G Thic11tsness: Viz d I _
Depth:Casing al- Dew: 1
Diameter: W'1
WeIght/ c:
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