GW1--01141_Well Construction - GW1_20240216

WELL CONSTRUCTION RECORD C
This form can be used for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information: I
•
Rex Meadows I4.WATER ZONES ••• • - • , .i . : . .
FROM- TO • DESCRIPTION I I
Well Contractor Name ft, ft. I
2113-A ft ft. I I . . . . .
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER Of an Beagle) .••
FROM To DutmETER " THICKNESS MATERLAL
Clearwater Well Drilling Inc. i D. U ft. 'a in:
Company Name' 16.INNER CASING ORTUBING(geothermal dosedgoop) •• -• •
" '
,� I�L'I(_ FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 202.2 p5"� ft. ft. in. I
List all applicable well construction permits(i.e.County,State,Variance,etc.)
ft. ft. in.
3.Well Use(check well use): I7.SCREEN'
.I:
Water Supply Well: FROM • TO • - DIAMETER' -SLOT SIZE THICKNESS MATERIAL.
OAgricultual ❑klunicipaVPublic n- • ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft, ft. in. i •
•
❑IndustriaUCommercial 133esidential Water Supply(shared) 18.:GROUT ) :
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Obrigaon
. ft'- C pI l ie nf n(I)1
Non-Water Supply Well:
❑Monitoring ❑Recov my ft. ft.
Injection Well: - ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation .19.SAND/GRAVEL PACK(If applIcable) ' . i, '
❑Aquifer Storage and Recovery ❑S8linity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
• ft. IL
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control .
'20.DRILLING LOG(attach additional sheets if necessary) '❑Geothermal(Closed Loop) ❑Tracer
FROM TO DESCRIPTION(rotor,barduev.sail/rock type.grain she.etc.)
❑Geothermal(Heating/Cooling+Return) ❑Other(explain under#21 Remarks) 1 ft. ill S ft. San/ 4 �I c r
4.Date Wells)Completed:L—{U/-ay'Weo ID# Q R �, ft- �1�t��( C
ft- [L aaa!!!
5a.Well Location: Jae) C OnSi UC1iOn �, I� C;t??��
►ems t cio�v�,+-n . �1 ft. .aasit. r�rc�,c�a e 1
ft. ft.
Facility/Owner Name Facility i139(if applicable)
R. iL
Davenport- Puce, 1 sheui 11/ IBC ` ` .: � ' >
ft. n. ; '
P cal Address,City,and Zip
it:REMARKS •m - r H 1,c 2U24
County Passel Identification No.(PIN) I
IntsCi it- iPO PrC;C t41.0 UM
fib.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certiiic 'on- • DWQMOf3
(if well field,one latilong is sufficient)
3.5 34—'ass N 7A Sin' DLQIo w ,— 2© 2*-
Sig sure of Certified Well Contractor Date
6.Is(are)the well(s): ermanent or ❑Temporary By signing this fonn,I hereby ccrtifi'that the imA(s)was were)constructed in accordance
with I5A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ,No copy of this record has been provided to the unit owner.
If this is a repair:fill out known well construction information and explain the nature of the
repair under it21 remarks section or on the back of this firm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.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 one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: .. aD S— (IL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wills list all depths(fd/•/ferent(example-3w00'and 2@l00) construction to the following:
10.Static water level below top of casing: COO (ft.) Division of Water Quality,information, ocessing Unit,
If rioter lerel is above casing,use"+" t G 1617 Mail Service Center;Raleigh,N 27699-1617
11.Borehole diameter: la I. (in.) 24b.For Infection Wells: In addition to sending form to the address in 24a
above, also submit a copy of this form within 30 ys of completion of well
12.Well construction method: . rot-cam{ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: • 1636 Mail Service Center,Raleigh,NC 27699-1636
I
13a.Yield(gpm) 15 Method of test: t 24a For Water Supply&Infection Wells: In addit on to sending the form to
the address(es) above, also submit one(copy of thih form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county heals i department of the county
where constructed:
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013

Wig Miner Self-Orout Cardikagen
Newel, 1/.
Addreerfq
Permit W2 -
I =dry that the above referaceotwell watt grouted in appetuanceii with
all CowtyWellrides.
wen Diger Rex Me_.dos
Gam aI.\3 _A a j-+119 -
Construed= Grout
Total nth; TYPet
Casing'rype: \ie, Thick nos: r iILE d •
Casing' Depth: (Q5 Mgr_ P
pianism kc6
Rive shoe:
GPM: k