GW1--06154_Well Construction - GW1_20230922

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
4 i �
Rex Meadows 14.WATER ZONES II
FROM TO DESCRIPTION I
Well Contractor Name rt. ft. I (
2113-A ft. ft. I
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)ORLiNER(If ap licable)
FROM TO DIAMETER, THICKNESS MATERIAL
Clearwater Well Drilling Inc. ft. f as ft C4 y g ;In. I'k Company Name 16.INNER CASING OR TUBING(geothermal cloied-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. 'in.
List all applicable well construction permits(e.County.State.Variance.etc.)
ft. ft. .in.
3.Well Use(check well use): 17.SCREEN I
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. fL In. 1
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft• in. 1
❑lndustrial/Commercial OResidential Water Supply(shared) 18.GROUT I
FROM rT1Oi1 /1MAATEE�RIALr� EMPLACEM� METHOD&AMOUNT
Non-Water Supply Well: ft. ou I _cement I ei It {�Il4lt
ft. ft.
❑Monitoring ❑Recovery
Injection Well: R. ft I
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(IfapplIcabte) I
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD .
ft. ft. '•
❑Aquifer Test ❑Stontnvater Drainage
ft. ft. i❑Experimental Technology CISubsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer - FROM TO DESCRIP I N(color,Mirdness,soWrock tape,grata she,ere.)
❑Geothermal(Heating/Coolingin Returrn)2 ❑Other(explain under#21 Remarks) ' fL tab ft. (sax) A r-
4.Date Well(s)Com leted:0 1-h 3 Well ID# ft' "' ft 1�t "�
P ,^ p
Sa.Well Locati -9W-1 ". ,Q+Yg ft• l re ce
Cole IZiddit, co f �� ft crOx feI
Facility/Owner Name Facility ID#(if applicable) [L ft • ;e P e .*� 't~��'
cbk N1orli n .Acres , Marshall 'e ft. ft. o; �
ern m Q fl 1
Physical Address,City,and Zip 21.REMARKS {l L t w J -�'
lAanliSOn
:r.py,..i.�- -� �,
County Parcel Identification No.(PiN) a ; n
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one latflong is sufficient) 22•C cation:
35' 45'.333 N �a'3s � aq? W )3-1va3
Si Certified Well Contractor Date
6.Is(are)the well(s): [iliermanent or ❑Temporary
B)•signing this form.I hereby certify that:the well(s)r ns(were)constructed in accordance
���(((- with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 ll Construction Standards and that a
❑7.Is this a repair to an existing well: Yes or iOo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information der`plain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well iletails;
You may use the back of this page to provide •tionai well site details or well
8.Number of wells constructed: construction details. You may also attach additio al pages if necessary.
Formultipleinfectionornon-watersupplywellsONLYwiththesameconsfruction you can
submit one form. _ SUBMITTAL INSTUCTIONS ,
9.Total well depth below land surfacer (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifddet-ent(example-3 00'and 2©100) construction to the following
10.Static water level below top of casing: O (ft.) Division of Water Quality,,Informs on Processing Unit,
If water level is abate casing; "+"roe C 1617 Mall Service Center,Ralei ,NC 27699-1617
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11.Borehole diameter: I Q I 0 rn) 24b.For Infection Wells: In additiJ n,to sendi g the form to the address in 24a
/� i� above, also submit a copy of this form within 30 days of completion of well
t�
12.Well construction method: 1 11+.! ‘j construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) 1.
Division of Water Quality,Underground njection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleig ,NC 27699-1636
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13a.Yield(gpm) Method of test: P,‘6124c.For Water Supply&Injection(Wells: in Jddition to sending the form to
f the address(es) above,also submit one copy oil this form within 30 days of
13b.Disinfection type i')1 wren C Amount: 0 Oar ce s completion of well construction to{he county ealth department of the county
where constructed.
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Form OW-I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013

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Wail Dater SoW-Iihmout Cordnaltion
Owner • m New
Pernatit —
I'hereby*WO:bat the above!ere:taxed well vas grained in appearance in acco with
all away Waldo.
well Miller, 91 6i MeOrb.,03 g •
Cerifacat #: c9 I
Dai0Grinitedt - I
COTISITUdOn: Gral)t
Total Depthz_AST__ grype;,
C.asing Tw r)V Thidanss: t.rc' ((kLi CA I
Casing Dth t mixt_ 20
Diameter LO`IS
weightfmkt,__.
Drive Shoe;
GPM. 'b
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