GW1--04146_Well Construction - GW1_20230623

WELL CONSTRUCTION RECORD Forinternal Use ONLY:
This form can be used for single or multiple wells
2.Well Contractor Information:
Rex Meadows 14.WATER ZONES _ i
FROM TO DESCRIPTION
Well Contractor Name ft. ft. I i I
2113-A It. ft. ' I
NC Well Contractor Certification Number IS.OUTER CASING(for meta-cased wens)OR LINER(If applicable)
FROM TO DiAMETEER THICKNESS MATERIALCleafwater Well Drilling Inc. Inrt. t E
n 1 43.tn. I NG
Company Name 16.(.NNER CAS G OR TUBING(tteothermat dosed-loop) i
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit/1: ft. ft. In. L
List all applicable well conrinrction permits(le County.State,Variance,etc.)
ft_ R. 1 In. "'
3.Well Use(check well use): -
17.SCREEN }
Water Supply Well: FROM "' DIAMETER ' SLOT SIZE THICKNESS AT ME21AL
❑Agricultural C1MnnicipnllPublic IL 1 TO it. In.
°Geothermal(Neating/Cooling Supply) Residential Water Supply(single) fr. I ft. In. I
D(ndueetria✓Commcrciai 111Reskdentinl Water Supply(shared)
Fd8t0 G,_O_L_I,TO i LLE U L if EMPLACEM
ENT
M_ H
OD&tMOUNT❑hi lotion � f zD f7_ + / VJNar-Wafer Supply Welt:
r
°Monitoring °Recovery ft �_rn R
lartiar.Weil:
�.__ i•` I . i
i:a t
I°Aquifer Recharge °Grroundwater Remediadnn 1 19.SA. :GRAVEL l'.iClt'tfA ..ten'ble
I°Aquifer Storage and Recovery °Salinity Barrier ` MOM f T MATERIAL EMPLACEMENT METHOD
I°A—tifer i t USiur_rtwir:r Orainace ( it
-- _-_. O �t✓. __ — —I
11--- Y
i c�l:ntic[iiiiciiiai Tcl'{_.tiUi•ig; tJJD'13S'denCe Control "-_ ( 1. .
• Zv. .'Yt�Lt i�aU.a.q.v in---:.p er;rliionrt st.:'y.s!..eer=e >_
It OCier,;er..ial(Clewed Loop) Miami-iae er rati;: �+, +++��-]]]]hill
_ ` r_ T.° DESCRIPTION ha /seestt►sall e=..,k�i Q:',— r.W`_
i OGa:fir: l l:{rngi._gi ling i to - S t ldr-is;ai • . _ :_ - 1 6 c�f•
sr -'-+ iJ J:l:�.f iC:�`•u/i: l i !
:..-. ...v C'_v i��----777 yi -rnairii) ////-�.�)) Lai
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�c.alw ice..: - - �.. _�SS_.-7'Z Tar.a:. A ...r I-1_0— s i ) a�• -- ._ 1
ell1,�.3i` �i: -f�-1 02,4164'— .�� 4,11
4, ( it_ i 2,• -s— r �J ,Q - — — �_i
r kr ifit. Elos-tr. a-vrl 5c-
N erCIAS . t heS LLC, IL lJJ ft.
FaciiityiOwner Nam UURI
9n FacilityID4(if/a/p�^plicable)Tl,/11 -
ical Address,City,and Zip ) n
r4/ Ka at S .�._ ,.. QCit.REMARKS I(�i� 4 /Q Z
County Parcel Identification No.(PIN) tE: *JCO r tc....rew... •.
[' _su54147,
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2. •tictttion:
Orwell field,one tat/long is sufficient)
)t54511 ,l Sg; 4�1 IG(0 w \-___, 2. S- -23
Sign, use ofCettified Well Contractor Date
6.is are the well(s); tilkFrmanent or CiTemporary Ity signing this form.I hereby certtfi•that the well s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Cacao-nation Standards and that a
7.1s this a repair to an existing well: DYes or D copy of this record heir been provided to the well on er_
if this is arepalr.fill oat known wellCanstntclittn information and explain the noire of the
repair under 021 remal*raection 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 well site details or well
8.Number of wells constructed: construction details. You ntayalso attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the snare Cecilruction•ypu c? _ _
g.'rotal well depth below land surface: —1 O� (to 24n. For Alt Wells: Submit this'form wit in 30 days of completion of weir
car nruitiphr,netts list ail depths ifdu/fntent(swamp!-31 200'and 244100 construction to the following:
Ie.Static:safer ls:el befew lop of ca erg; _ (IL) Disii:on al V ater Quality,liffetrisuuu k iime5Sirig visit.
if wiei✓r tn.r.t iv°heartnnein ?Tr..4..l !f.:7 :::::.ai-r Li;C:uw .
- . r .. ..__ _ ..
1 1.Borehole diameter: �-�` � —(in.) 24b.For in jtrtton Welts: In addition to se,Kama the form to the s c rldre.,_ in la..•:---__ ,,,.. .-,aui_.;�_ii ... u.a; I' VA,.i. 3i:ii,iJc: 0 {ai%tVei:,iiii, 81 SoCii
1 ,WO etrtrsiruciion mHctLod: __ construction to the following.
(l....u.i�.aa.ay.y,a.G'.c,tin0.L pU3r.,CW.)
_ Di r'- ,dear 1ialai4,t•'udergreenti Injection Control Program,i - �iiz.i of 4
iFAD Tea.*A-rr.D 4`rraDT A.r WL.r£o"N.,v_ ..._.�...- t a�..- .::f....._..—:.,..^:"_' r_ +... ....r..._ ..v._
13a.9rlela t 24e For Water Solt >P Wag rl.
to:mi� _--- air.att of loci• G ✓ n!= .)diet L e�;=-n lido tv ser3in rrw�f w;:t rc.
the address(es)above,also submit oiie cop of this form within 30 days of
1 fib.Disinfection type:°-��0` l Amount: I 10v completion of well construction to Cite coon r health department of the county
"==3'.':: a.v.i;.Ca.vii.m i.spntuncm.al envirunmenr ana&Natural Resources-i)nnsmn ot"Water l uali
Q, Y Revised lan.2013

•
Well Driller Self.Srout Certification
I,am.qe( C . 064,
Owner:( UtYCuS Koperti esL.L New Well: V
M Clik-C Repair:
s
z l er certlfytbat the above referenced well was grouted in appearance in accordance with
all County Well rules.
well Diiner,16 k I>keadv c s; ecl .�--_.--------
cerd icate#: 7,113 `.A- Date Grouted: E-zs.- 3
Cousuarn: Grout:
Total Depth: 7 05 T M
Casing Type: Y" c, Thickness: mkt-to
Casing Depth: Depth:Depth: cl)
Diameter: la`1
Weiglttingdc
Height:
Drive
curs t