GW1--03168_Well Construction - GW1_20240524

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information:
Rex Meadows 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft
2113-A ft. ft. -
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Clearwater Well Drilling Inc. FROM TO DIAMETER THICKNESS MATERIAL.
Iit. I Lip ft. f (I t l�)in. 3
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAl,2.Well Construction Permit#: ft. ft. in.
List all applicable well construction permits(i.e.County.State,Variance,etc.)
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft, in.
❑Geothermal(Heating/Cooling Supply) 'hQResidential Water Supply(single) ft. R. in.
❑Industrial/Commereial '❑\Residential Water Supply(shared) 18.GROUT
FROM1L TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ElIrrigation
Non-Water Supply Well: ft. ZV ft. 'f1( 1j" ,' i` 9�-t
�sr t" ,y
❑Monitoring ❑Recovery ft. ft. (1 I
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if appticablA -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
ft. ft. -
❑Aquifer Test ❑Stonnwater Drainage
ID Experimental Technology ❑Subsidence Control ft. t ft.
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothetmai(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size,etc.)
❑Geothermal(Heating/CoolinIg11Retturn) ❑Other(explain under#21 Remarks) , ft• I t,1 5';, H, '(ha( l 1 r C� 1�
4,Date Well(s)Completed: `(`1` �1" Yell ID# O it. 1 I fL at� 1
5a.Well Location: 511 R. 31 ZR.
M n Mcs 21 ?. rt. 505n. c -
��.yJ1 H. ft.
Facility/Owner N me Facility IU#(if applicable)
- 5 ‘10,0,A6 C6 . IL ft. .
•
Physical Address,City,and Zi Y,-•Li
nj j ,\C 1 L/v" 21.REMARKS 1/Ar 2 2n
County LT Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Cer iHcation:
51 ' N '3g, 33S W 4 70 21
"� Sig ofCerti led Weil Contractor Date
6.Is(are)the well(s): �t ermanent or ❑Temporary
/� By signing this fora. I hereby certifp that the nrI1(.)tins(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 5A 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 tee!!owner.
If this is a repair,fill out know?well construction information and ee..plain the nature of the
repair tinder#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-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below lanes surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3ta200'and 2(t000') construction to the following:
10.Static water level below top of casing: W D (ft.) Division of Water Quality,Information Processing Unit,
If water level is abuse casing,use•'+' \ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: LY (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: I p-c tito above, also submit a copy of this form within 30 days of completion of well
I li}{ 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) 1 Method of test: it C 24c.For Water Supply&Injection Wells: In addition to sending the form to
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 GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

Well Defiler SeIf-dineut CortiS Mrtiun
Owner _S New Weil. v
Permit
I hereby certify that the above lefenitced well was grouted in appearance in accordance with.
all County W n .
wail
211 J Die Groutect �Z. T
COnStr'ld10'1: C n
Tca►Depth; 505 TY1e: .�
Cagng : Thickness: m-
Caging : :_
Diameter: (Q
Weightilltdc
Drive shoe:
GPM