GW1--01779_Well Construction - GW1_20240320

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells I For Internal Use ONLY:
1.Well Contractor Information:
Rex Meadows 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2113-A f. f.
NC Well Contractor CeriiEcotion Number 15.OUTER CASING(for multi-cased wells)OR LIVER(if ap Me)
Clearwater Well Drilling Inc. FROM110 ft IL°
L°M1TM►CKNESS MATERIAL
DIN IJ in. e 1
Company Name CASING OR TIMING
O� PROM TO (geothermal closed loop)
2.Weil Construction Permit#: —I 1 DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.Coe ft. ft. in.
/x (� County.State.Variance.etc.)
R. ft in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultu al ❑Municipal/Public R ft. in.
❑Geothermal(Heating/Cooling Supply) XResidential Water Supply(single) R ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) l>L GROUT
❑Irrigation FROM TO MATERIAL
EMPLACEMENT ETHOD&AMOUNT
Non-Water Supply Well: i ft. 00 ft. ee. IC M1 K,a
❑Monitoring ❑Recovery ft ft.
injection Well: rt. ft.-
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Of applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑A uifer Test ft. I.
9 ❑Stonnwater Drainage
❑ExpenmenW Technol rt. H•
�Y ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets iaeeessary)
FROM TO DESCRIPTION color,hardens,soNrack type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ! n• 10 ft. d''.
4.Date Well(s)Completed:a--•5-2-1 Well IDS/ `-y D R' 31 q- ft. 1-9k-Ownl+e--
5a Well Location: 3Ilt rt. �l� H �'
ChoLvk Dodson s:. qos-ft. , c3racAtie
ft .
Facility/Owner Name Facility II)#(if applicable)
ISM 1'646 jJ • Q;kik(Ctta " k)G f. t
ft ft `'
P lys/.ical City, Zip
l t 21.REMAwts +/l� 1
I0 piq
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: >,i ,
rit.(if well field,one lat/long is sufficient) 22.C Motion:
au' 3 ' a'3 N Ba . I a ' t aco W .-"---,_ c) - 4 -ay
Si of citified Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary
By signing this form.I hereby certify that the well(s)was(*ere)constructed in accordance
,,yy((�• with 154 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 to copy of this record has been provided to the well owner.
)(this is a repair.Jill out knoan well construction information and plain the nature of the
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 additional pages if necessary.
For multiple injection or non-muter supply wells ONLY with the same construction,you can
submit one form. a SUBMITTAL INSTUCTIONS
9.Total welt depth below land surface: TV 5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2(o1.1100') construction to the following:
10.Static water level below top of casing: (.00 (ft.) Division of Water Quality,information Processing Unit,
If water level is above casing,use"++" 3 1617 Mail Service Center,Raleigh,NC 2 7699-1 61 7
11.Borehole diameter: (.12t l (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
I
12.Well construction method: I 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
13a.Yield(gpm) 50 Method of test: 9 24c.For Water Supply&Infection Wells: in addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

WeNWows.M-*r CordiNcation
Owner: arl� 0 of son
Addres:I (2t+.t f) d
Perntit
I hereby ontlfythat the above referenced well was grouted in amearance in accordance with
all County Well mks.
{
UlDd(51/05 spa:well nrme� .X
Certificate#: a113 -A- Date ca: p
Construction: Cm
Total Depth: `PS- Type Ce-MtAkk
Cash*Type: SA-ee I Thiriness: jYl\wc d
Casing Depth: 1D : 2�
Merrier: Co (C
Weight/11* :
refire shoe:
GPM u