GW1--06157_Well Construction - GW1_20230922

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WELL CONSTRUCTION RECORD For Internal Use ONLY: I
This form can be used for single or multiple wells
1.Well Contractor Information:
Rex Meadows 14.WATER ZOO I i
FROM TO DESCRIPTION
Well Contractor Name ft. n. I
2113-A ft. fr. I I I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER ap Beside)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling inc. I ft. 4 IL L e\ in,
I Na
Company Name 16.INNER CASING OR TUBING(gcothermnTc14sed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. , in.
List all applicable well construction permits(i.e.County,State.Variance,etc.)
R. it. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public rt. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R' R' in. I
OlndustriallCommereial ❑Residential Water Supply(shared) 11.GROUT
FIROM t TO /�MpATTEERRIIA�L EMPLACEME
NT METHOD&AMOUNT
❑Irrigation 1 ft.,9lJ ft- 1 .e a /K 1 Lt
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery "
injection Well: • ft. ft. + I
❑Aquifer Recharge . ❑Groundwater Remediation 19.SAAND/GRAVELPACK(if applicable)
uifer Storage and RecoveryFROM TO MATERIAL EMPLACEMENT METHOD
❑A
4 g ❑Salinity Barrier ft ft.
❑Aquifer Test OStormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. I
❑Geothermal(ClosedLoop) ❑Ttacer 20.DRILLING LOG(attach additonr l sheets if ne&essary)
FROM TO DESCRIPTION color LWness,saIitrock type,grain size.de.)
❑Geothermal(Heating/Cooling Retturn) ❑Other(explain under RI Remarks) I it' VACi it- SW 4•- c Y+-
4.Date Well(s)Completed: V- 4 13WellID# (-Vt" ft. 1k)z_ *ni-i.c.weu LocatiDn: 101". lC; n. �p)
n(� ,} ( � tO3 ff. I4S ft. t�21
^y r l A Vl�� l l�J1 ft. ft. `
Facility/OwnerNar 1 Facility ID#(if applicable)
E R+ e_Tr�e Dr. Marshal l JC ft. L I A �,�,
Physical Address,City,and Zip 2L.REMARKS I C r-rt
N1fA�iSGn �t-t L�13
County Parcel Identification No.(PiN) i ifi`rv1`rTi"S(i )tror�r.
� .ell 1 IrA.
5b.Latitude and Longitude in degreeslntinutes/seconds or decimal degrees: 2 ertifi odor: ' • Lit;dt.lts.?G�
(if well field one latllong is sufficient)
?�5°51 ` �-�`? N ��' �ln 1�� W -g- 3
Si we o Certified Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form,I hereby cerlit,that the nell(s)rtus(sere)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Jr it Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or )4No copy of this record has been provided to the well owner.
If this is a repair.fill out known well construction information and explain the nature ofthe I'
repair under#2I remark section or on the back of thisfamt. 23.Site diagram or additional well details:
You may use the back of this page to provide a 'bona!well site details or well
8.Number of wells constructed: construction details. You may also attach additio 1 pages if necessary.
For multiple injection or non-water supply wells ONLY with the sane contraction,you can
submit one form. SUBMITTAL INSTUCTIONS ''
9.Total well depth below land surface: !`k'!`C✓ (ft.) 24a. For AU Wells: Submit this form within 30 days of completion of well
For flush/pie wells list all depths IIfdi erent(example-3C200'and 2(100') construction to the following
10.Static water level below top of casing: 3D (ft.) Division of Water Quality,Iinfonna ion Processing Unit, _
Ifwater level is above casing,use"+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
llnn
11.Borehole diameter. �.1/ t1 (in.) 24b.For Infection Wells: In addition to sendi g the form to the address in 24a
�}.� 1 above,also submit a copy of this form within 30 days of completion of well
12.Well construction method: 1 l> W 1Ji construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) ,
Division of Water Quality,Underground jection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cen ter,Rateig ,NC 27699-1636
13a.Yield(gpm) CDS- Method of test: kI9 24c,For Water Supply&Infection Wells: Ina dition to sending the form to
`
13b.Disinfection typeeb 1011
ryn ^K n i I the address(es)above,also submit One copy off'this form within 30 days of
L1i 11 t Amount:_ -Ct.. Iy�CAJ) Completion of well construction to i e county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

Well Near Solf-Orout Corldniurden
owner
r
Permit
I hereby ostifythat die above referenced well was grouted in appemance:in=cadence with
all County Well rain
wen Driller -eaCkUO3 ,
Certificalat a ‘?7.)- Dare Grouted:
Construed= Grout
Total Deptin 4S- Type:
CaghlgT,Pe: Thielows: (Y101-LCi
Casiag DePth: Depth: -D
Dimmer ( tO 1,
Height—,
Drive Shoe:
GPM:, sc9