GW1--03165_Well Construction - GW1_20240524

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
• Rex Meadows 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name - ft. R.
2113-A ft. ft.
NC Well Contactor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. ft. Li) ft. '[ cm .in. '.i'�( .
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)01
(Q( �, FROM TO DIAMETER THICKNESS 51ATERtAL
2.Weil Construction Permit#: "r ft. ft. In.
List all applicable well construction permits(i.e.County.State.Variance,etc.)
ft ft. iR
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural DMunicipal/Public ft. ft. in.T
❑Geothermal(Heating/Cooling Supply) j esidential Water Supply(single) R. ft' In.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT ETHOD&AMOUNT
❑Irrigation ff. r \ ft. 1 1
Non-Water Supply Well: „� (�1�� � l� 1 ��
ft. U.
❑Monitoring ❑Recovery
Injection Well: ft. ft. .
°Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Storage and Recovery OSalinity Barrier h. ft
°Aquifer Test DStormwater Drainage ft. ft.
°Experimental Technology ❑Subsidence Control 20.DRILLiN G LOG(attach additional sheets if eecasary
)
CI-Geothermal(Closed Loop) °Tracer FROM TO DESCRUF'LION(colter,hard toll/rock 4pr,grain sire.etc.)
°Geothermal(Heating/CoolinglIReturn) ❑Other(explain under#21 Remarks) I f' i ,1'`', ft' �`?C/Li �'� , y-
4.Date Well(s)Completed: `-t-k I-CIL' Well lD# �1�1 n' ��y re (f�! 1 (�1
�.! t 1 R. l 1 `S ft. �I li ()�C
Sa.Well Location: JriC e C-c'f Ts 1 Ti.i C_16 423-1 r'T �[ y (1�Y
-(� ,S ft' 505R. f,l.11 `/i
k l U(- 4v 1 ii r( C �i e 1-)cAc 4 C Ll I C V l ft. rt.
Facility/Owner Name '' Faci18y)1DN(if applicable) R. [t. —r,.+
i kALVA,QiL r.pp idle- i- ft. rt.
Physical Address,City,and Zip 21.REMARKS T t!024
41-neeLI �hAY2Co Parcel Identification No.(PiN) ��
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 21.Certlfl bon:
(if well field,one laulong is sufficient) ,
35' 5_1" /57 N W., /q �-7 V W ��,�- y -1 ) ) li
Signal ofCutified Well Contractor Date
6.Is(are)the well(s): ertnanent or t7Temporary By signing this form, I hereby cenif-y that the tieIlls)um(nrrel constructer/in accordance
with I fd NCAC 02C.0/00 or 154 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ClYes or tko coNy of this record has been provider)to the melt owner.
If this is a repair,Jill out known well construction information and explain the nature plate
repair under 021 remarks section or on the hack of this fano. 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-water supply nulls ONLY with the same construction,you con
submit one Orin, SUBMITTAL 1NSTUCTIONS
9.Total well depth below land surface: :mil ). ) (ft.) 24a. For All Wells: Submit this faun within 30 days of completion of well
For multiple nulls list all depths if different(example-3�d200'and 2#i 1001 construction to the following:
10.Static water level below top of casing: 0 O (IL) Division of Water Quality,Information Processing Unit,
{)'outer level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
'C.
Ii.Borehole diameter: 0 (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
1 , /} / above, also submit a copy of this form within 30 days of completion of well
pl!12.Well construction method: t iLti, construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
h,NC 27699-1636
1636 Mail Service Center,Raleigh,FOR WATER SUPPLY WELLS ONLY: ) S
13a.Yield(gpm) Method of test: (-1(- "f 24c.For Water Supply&Injection Wells: In addition to sending the form to
r the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
13b.Disinfection type: Amount:
where constructed.
Form OW-I North Carolina Department of Environment and Natural Resoracrs--Division of Water Quality Revised Jan.2013

•
Wed Dries' Satf-Oirout Grri dioon
Doi- \j llt"K _
Owner: -)1( New
I bertby certify that the above referenced weu was grouted in appearance irk aCCOltiance with
all County Well mks.
well -�� y
Ce�rdfica : 0 l l 3 ADate
Construction: Grout
Total , ,� � TYPe=—C. -
Casing TYPe: pve, Thickness: (YVIkt
Casing • t0
Diameter: W. � -
Weight/Thick ,
Drive shoe:
GPM 't
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