GW1--01112_Well Construction - GW1_20240216

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Rex Meadows 14.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name R• R.
2113-A R. R. I —
NC Well Contractor Certification Number IS.OUTER CASING(for multi-eased wells)OR LINER(if ap l[cable)MATERIALFROM TO DIAMETER THICKNESS MATERIALClearwater Well Drilling inc. t rt. el5 to`{` in. I j pv e
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. It. in.
List all applicable well construction permits(i.e.Cou,Uy State,Variance,etc.) It. ft. ia.
3.Well Use(check well use): 17.SCREEN 1
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. iR. I
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
Olndustrial/Commercial ❑Residential Water Supply(shared) 1RGROUT 1
FRAM 'T7O /LM�ATERIAL�.l.. EMPLACEMENT METHOD&AMOUNT
ONon-Water on Supply Well: ( ft' c O' rem ►t l '� \,\ -A(al
It. ft. I
°Monitoring (]Recovery
Injection Well: ft. ft. I
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Of applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO afATERiAL; EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑StormwaterDrainage
ft. ft.
❑Experimental Technology °Subsidence Control
20.DRILLING LOG(attach additional sheets If necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soli/rock type,groin sire,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1 ft, rDS R. F3 y�,,Irci —tia-CA-
9S7
4.Date Well(s)Completed:I- J a Well ID# ' 3 R. 1 t c`i-
ft.
3T1'' -31 • OrPAci2
5a.Well Location:/ ` `r ?"I�l'L i t t'��fL t a; t„Ile
Dab a 1 ;�iN n cc ]t H. go sit R. J rb 7 ,,.r'i-...n �t......>
Facility/Owner Name Facility iDO(if applicable) R, ft. 8 b%. iL...L If «S....tt,,,,•
2.)N 143 nPilLit Ppm(It ex_t ttrl .. It. ' FEB 1 C 2024
Physical Address,City,and Zip 21.REMARKS 1
M01(-4'Cn riti3iic^:)c?r::f•; ✓a1:f:b lift
County Parcel Identification No.(PIN) E./VI/t.t!tti
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:�22 C cation:
(if well field,one lat/long is sufficient) �y�' • a t'�
G2 ' S l '` iC) N V2 31 ` 3C 1 W /l.`._---- I - -T - E
S" we of Certified Well Contractor 1 Date
6.IS(are)the well(s): etmanent or ❑Temporary signing this form.I hereby certt&that the uell(s)ace(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or 3o copy of this record has been provided to the well owner
If this is a repair,fill out knonn well construction information and explain the nature of the
repair under 021 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 dditional well site details or well
•
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple infection or non-water supply wells-ONLY with the same construction.you can
submit oneform. l ' SUBMITTAL INSTUCTIONS 1
`Y
(ft.) 24a. For All Wells: Submit this
9.Total well depth below land surface: °� farm within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3( 200' �/and 2©100') construction to the following:
10.Static water level below top of casing: C (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing.use"-I-- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (.0'/ O (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
{�� above,also submit a copy of this form with' 30 days of completion of well
12.Well construction method: V lc construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) P
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ©© 1636 Mail Service Center,Ralei h,NC 27699-1636
13a.Yield(gpm) 3 Method of test �4c Z4c.For Water Sunaly&Injection Wells: In I ition to sending the form to
the address(es)•above,also submit one copy f this form within 30 days of
�Jn /1 completion of well construction to the county health department of the county
13b.Disinfection type: it+� Amount: �� ) where constructed.
Form GW 1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013

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