GW1--03208_Well Construction - GW1_20240524

WELL CONSTRUCTION RECORD Far Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Rex Meadows FROM TO DESCRIPTION
Well Contractor Name It. f•
2113-A ft.
It.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if ap 8cable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. 1 ft i a ft. LQ `i2 in. PVC
Company Name 16.INNER CASING OR TUBING(geothermal dead-loop)
O n3 V ,(1 IVycJ)V�11 h FROMtt. TO
R. DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: C7t Da is
List all applicable well construction permits(i.e.County.State.Variance.etc.) ft.
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: , FROM ft. TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural ❑Municipal/Public
°Geothermal ft. It. in.
(Heating/Cooling Supply) I�esidrntial Water Supply(single)
0IndustrialCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD 4 AMOUNT
El Irrigation j I. of`J /I ft. /�MOIi'lt- (n t i,[,td
Non-Water Supply Well: I ft. ft.
1 'l.l
[Monitoring °Recovery
Inieetlon Well: ft. R.
[Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. R,
°Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology [Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) [Tracer FROM TO DESCRIPTION calor,hardaas,sail/rock type,grain gee,etc.)
❑Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) 1 R• 1 og I• �1'CI,t�(-A
l,,_30-Z - `IA ft 33C IL cart
4.Date Well(s)Completed: ell 1D# ♦ ft tt
5a.Well Location: A •erSiQ - "' • 'ems•' �" R \��"R {� �er1 1 ^ v R• sue/ 9Cfli4l
Facility/Owner Name Facility ID#(if applicable) R. R. s
55 Netri r Ave, .e, . Y eLtver\f‘ NE 1Lt, R. ft NZL4.PE VE[)
P ical Address,City,and Zip 21.REMARKS I!EAY 2 i 2024
County Parcel Identification No.(PIN) irii.+r4,A'r:;p••r;ryt'447-1:licit
5b.Latitude and Longitude in degreesiminutes/secoDds or decimal degrees: •
22.Certir don:
dR^�..,�y
(if well field,one ladlongisis sufficient) n 7 (
Lk-AA klSlo N �V�, 35' 3v� W .�„�'� a� "`' •
Si of Certified Well Con hn2ty ! Date
6.Is(are)the well(s): Aermanent or °Temporary By s wing this form.I hereby certifp that the nell(s)was(were)constructed in accordance
with 1 SA 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 well miner.
If this is a repair,fill out brown well construction information and explain the nature of the Site diagram or additional well details
repair under#21 remarks section or on the back of this form. 23 •
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 SUBMITTAL INSTUCTIONS
submit one_form.
9.Total well depth below land surface: ( )
O J ft, 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(crumple-3 a�00"and 2Gl00•) construction to the following:
10.Static water level below top of casing: LOD (ft.) Division of Water Quality,Information Processing Unit,
if
I/'water level is above casing,use"+"r 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: LQ I v (in.) 24b.For Infection 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
12.Well construction method: rOin Iq 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
24c.For Water Supply&Injection Wells: In addition to sending the form to
13a.yield(gpm) 5 Method of test the address(es) above, also submit one copy of this form within 30 days of
Amount: completion of well constmctioo to the county health department of the county
13b.Disinfection type: where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

�nIS��TCI
---7771.--radicL Sumo
--=em5- JAME gam
vial WWMAlunO ttW