GW1--06153_Well Construction - GW1_20230922

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells JFor Internal Use ONLY:
1.Weil Contractor Information: I
Rex Meadows 14.WATER ZONES r 1
FROM 1 TO DESCRIPTION -
Well Contractor Name - R, ft.
i
2113-A ft. ft. I i -
NC Well Contractor Certification Number 15.OUTER CASING(formultl•cased wells)OR LINER Of ap !feeble)
-
Clearwater
Well Drilling Inc. ' THICKNESS MATERIAL
FROMR +(T�jOp� fDIAME j
1 - R' t—It) ft 1IQt' O pin. I ` 1,iC
Company Name I6.INNER CASING OR TUBING feothermal ddsed-loop) 1
FROM TO l DIAMETER THICKNESS MATERIAL
2.Well Construction Permit it: ft a I,In:
List all applicable well construction permits(1.e.County,State.Variance.etc)
ft: ft, via
3.Well Use(check well use):
17.SCREEN f
Water Supply Well: FROM TO DIAMETER Star NEE THICKNESS MATERIAL
°Agricultural ClMunicipal/Public R R. in I.
OGeothermal(Heating/Cooling Supply) AResidential Water Supply(single) ft. ft. in. I
Olndustrial/Cominencial []Residential Water Supply(shared) 1&GROUT • 1
Obligation TO WWI
nMPLACEM METHOD&AMOUNT
Non-Water Supply Well: 1 D. AD H• 111 t Ix U. �
°Monitoring °Recovery ft. R
Injection Well: • - ft. R
[(Aquifer Recharge °GroundwaterRemediation 19.SAND/GRAVEL PACK(lf applicable)
°Aquifer Storage and Recovery 17Salinity Barrier FROM TO MATERIAL 1' I EMPLACEMENT METHOD
IL ft.
°Aquifer Test °Stonnwater Drainage
°Ex erimental TechnologyIt. H. �, i
P OSubsidenceContro}
°Geothermal(Closed Loop) °Tracer •
20.DRILLING LOG(attach additional sheets if aetiessary)
FROM TO DESCRIPTION(color,harda sol track type,grata size,etc.)
OGeothermal(Heating/Cooling Return) °Other(explain under#21 Remarks)_ I R• (,t 0 i• (_' ry i q-av i-
4.Date Well(s)Completed: O—S-p� ,Well ID# (4.0 ft- r,.".� l � �(�,
5 Well Location:
1 � +D II
b'C i ((ill Alt R. c_J fit03 Il L d G"v i :e..
Facility/Owner Name Lo+ kk i Facility lDtk(if applicable)
ft. tt. ��SE }
likAtw to Acres br . Mair5h(ii )C r SEP 2 2 2023
Physical Address.City,and Zip
And (� 21.REMA'RKs i_ infra;ays:,iPil?r;+.owa!nst (jRk
(ST)rI � MN Cer`+�JG
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2 .Ce &anon:
(if well field,one lat/long is sufficient)( q�
(5n b t 3(-5 N Bi7C i t.\/ ll n W ✓try 1 ? -(3 -Z
Signs use o edified Well actor 1 Date
6.Is(are)the weU(s):XPermanent or °Temporary
By signing this form,1 hereby cent&that the well(s)um(were)constructed in accordance
with 15A NCAC OW.0100 or 15A NCAC 02C.0200 We l Construction Standards and that a
7.Is this a repair to an existing well: °Yes or Oi to copy of this record has been provided to the wall owner.
If this is a repair.fill oat known well construction information and explain the nature of the
repair under 021 remarks 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 ad.itional well site details or well
B.Number dwells constructed: construction details. You may also attach addition-I pages if necessary.
For multiple infection or non-water supply wells ONLY with the same construction,you can
submit one form. 22 JJ�� SUBMITTAL INSTUCTIONS
LJ(1
9.Total well depth below land surface: 5 (1t4 24a.For All Wells: Submit this form within 0 days of completion of well
For multiple stalls list all depths idf/erent(crumple-3(✓200'and 2(§100) construction to the following: i
10.Static water level below top of casing: co D (fit.) Division of Water Quality,if nformati.a Processing Unit,
If water level is above casing,nee"++ (" 1617 Mail Service Center,Raleigh NC 27699-1617
11.Borehole diameter: (0 ti 8 (in,) 24b.For Infection Wells: In addition to sendin;.the form to the address in 24a
yo above,also submit a copy of this fond within 0 days of completion of well
12.Well construction method: 1 ll construction to the following: I,
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground In ection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mai Service Center;Raleig NC 27699-1636
13a.Yield(gP>n) l Method of test: kg 1.
24c.For Water Supply&Infection Wells: In ad.ition to sending the form to
the address(es)above, also submit ones copy of his form within 30 days of
n�
13b.Disinfection type:(2J 31 OQ1 h Q Amount: () completion of well construction to the county health department of the county
where constructed. I
Eorm OW-I North Carolina Department of Environment and Natural Resources—Division of Water Qualityl Revised Jan.2013

Wel Mar Self-Grout Collaudkon
CO16 RI(Ac New Well:
lit ►� Addrestc M0X crC
Marshy 11 �-
ihereby certify fhat ihe above referenced wen was grouted i►appearance% with
an County Welinits
Well Miter eMeadO101 S` • 2
� : DalAGrouird . 3-3-(23
ccnga.macs: Grout
Total Depth; ,305Typm. Ci yi")f
casing Type:_pv , : ``C1+ d
Casing : QV
Diameter: (Q'I�
Melt—
Drive Shoe: