GW1--00669_Well Construction - GW1_20240125

I
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
1.Well Contractor information: I
Rex Meadows 14.WATER ZONES
FROM I TO 1 DESCRIPTION I
Well Contractor Name R. ft I I ,
2113-A R. ft. I I
NC Well Contractor Certification Number IS.OUTER CASING(formulU.easedwells)OR LINER(Nap ltcable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. \ R- Ia3 ft. 1 i�%' in• i J ry ,C,
Company Name 1 A 16.INNER CASING OR TUBING(geothermal do}ed-loop) 'S
2.Well Construction Permit#: `. J\ — 50 i W FROM
�t TO DIAMETER TmQNESS MATERIAL
it ft. to
List all applicable wall cancsmretion permits(i.e.County.State Yarianm,etc)
ft. f4 in.
3.Well Use(check well use): 17.SCREEN j
Water Supply Well: FROM TO DIAMETER' SLOTSJZF THICKNESS MATERIAL,
❑Agricultural °Municipal/Public ft. In.
OGeothemial(Heating/Cooling Supply) residential Water Supply(single) R. R. "t. i
Oindustrial/Commercial ❑Residential Water Supply(shared) IS.GROUT I
❑lrrigadon FROM MATERIAL EMPLACEMENT METHOD&AMOUNT
` R.Non-Water Supply Well:
2-0 ft'
CPS i (`{ll q%� C�
❑Monitoring °Recov R• ft.
Well: ft. R. 1.
°Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable) I
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
R. R.
°Aquifer Test OStormwater Drainage
❑Experimental Technology °Subsidence Control rt.
❑Geothermal(Closed Loop) OTtucer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(cater,taudaess,soWrack type.prate she,eta)
f7Geothermal(Heating/Cooling�Return) ❑Other(explain under#21 Remarks)_ ) ft• r9A O• Nin'/11 4_ ,/.lam
4.Date Well(s)Completed: I U�'(-1v2•,--a nVeell m C M — n 5 3pnt(/j '�y V i
5a.Well Loca'lo: .' S 1 &f 1 CO J `/�1/t2 Ili/ V Li' [Ii
j1 l � oA t i W1 1 Vk 0 Q ll�c6 ft. ft. }
Facility/Owner Name Facility ID#(if applicable) ft. ft, C-� �` I
0� 1 Dr. R. fc 1 .t G
L 1 LAC' i tee ft. ft. n r.
Physical21.REMARKS ' ti `� ��-.
y dress,City,and Zip .•e,,,, s a f ,; C.r C
lkerodk JAN 2 f 9n
County Parcel Identification No.(PIN)5b V 2 j
(if Latitu a and Longitude in degrees/minutes/seconds or decimal degrees: ( 2 Ce tica6on: �6 �RIt(if well field,one latRong is sufficient) 'G
ar 1 a \ N �a' .BPi 51a W .� - , }Z-% _2-
Si f Certified Well Contractor ' I Date
6.is(are)the well(s): (tkermanent or OTemporary Bysigning this rm,I herebycent*that the lie/1 s u r r \\ brag fo .l) () (were)constructed in accordance
`/ with!SA NCAC 02C.0100 or 1SA NCAC b2C.0100 Wet!ConstructionStandw ds and that a
7.Is this a repair to an existing well: ❑Yes or L io copy of this record has been provided to them)!ell owner.
If this is a repair,fill out known well construction information and explain the nature ofthe 1'
repair under#21 remarks section 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 may also attach additio I i pages if necessary.
For multiple injection or non- atersupply wells ONLY with the same construction.you can I
w
submit one form. ff ,l!^, SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: —1 l. S (ft.) 24a. For All Wells: Submit this form within 0 days of completion of well
For m hiple wells list all depths(fdderent(example-3@200'and 2@100') constriction to the following: !'
10.Static water level below top of casing: L.0 O (fL) Division of Water Quality,Informatiqon Processing Unit,
Ifwater level is above casing,use''•+•' 1617 Mail Service Center,Raleigd,NC 27699-1617
(
11.Borehole diameter: MIL � (in,) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form withinJeetion
0 days of completion of well
12.Well construction method: in--O,Vkit construction to the following: {
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground I Control Program,
FOR WATER SUPPLY
^W IELLS ONLY: 1636 Mail Service Ce iter,Ralelg NC 27699-1636
13a.Yield(gpm) \ f/ .- Method of test: q
24c.For Water Supply&Infection Wells: In a dition to sending the form to
the address(es) above,also submit one copy ofj this form within 30 days of
13b.Disinfection type: Amount: completion of well cpnstruction 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 Q Ility Revised Jap.2013

Wdl Drifts Sdi6.nut emtlikagen
ovaier: i 11 Ronywr\rto NWek
Addrealacidapili
Pantt 3DA0
thereby oesigyfbat the aboverefemeed wall use paned in Diu madame with
all County Wdl tales.
Well Meer. Roc \\A'r,--0c0)33 •
ceratage#: 2.1 . Dawortouted: z
Construed= Gant:
Tot*Depth; COM-EU/Li
TYPe
Casing'rype:. Titaness:
Casbsg Depth: Eeprb:
Diameter
Height—,
DriveShoe;
GPM: