GW1--03661_Well Construction - GW1_20240618

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. ft.
2113-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap plicablc)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. ( ft. / ft. l.i?•t , in.. PVC
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
ft. ft. in.
❑Agricultural ❑Municipal/Public
OGeothermal(Heating/Cooling Supply) Xtesidential Water Supply(single) It. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT _
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation ft I It. .
Non-Water Supply Well: i �L) `� •� ► 1 `� l �
ft. ft.
❑Monitoring ❑Recovery i
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicaL)
FROM TO MATERAAI. EMPIACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
0 Aquifer Test ❑StormwaterDrainage ft It.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) l It. 1 fL (-'f`l, V ) ..i (-�f;'I( 1
4.Date Well(s)Completed:D-I )H Well ID# II °--9t. G�l�t 0. l �'t LS T
5a.Well Location: C rD i ft• . JAR. ()calm v
�1 CIS► t-.1 4-- :Sarni e Ter) ►(-)_
n. H.
Facility/Owner N me Facility iD#(if applicable) -- .'',l"'
11))0 U -VP. Q i y1P_ 1i, , M(� S�' Cc.t) ft. D. �r�:.
Physical Address,City,and Zip 4 r,/ 21.REMARKS f U N 18 2024
CcitS X\
County Parcel Identification No.(PIN) v l�`C lB6-g I1
ei
tin.!l..t4
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifi lion:
(if well field,one Iat/long is sufficient)
35 ' L.V . 35Z` N ' 4 ��q i w 5 -3-2 9
Signal rtified Well Contractor Date
6.Is(are)the well(s): �1Permanent or OTemporary gt•signing this form.I hereby certh•shot the well(s)wns(were)constructed in accordance
' with 15A 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 site well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the bock 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
6.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 land surface:p C) D ((t.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(cramp/e-3@200''and 2@100') construction to the following:
10.Static water level below top of casing: ( 0 0 (ft.) Division of Water Quality,information Processing Unit,
If water level is above casing,use"+' l 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: Li) u (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
12.Well construction method: rU+f/��{1 r l.1( construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY: � g
} ` t�I 24c.For Water Stlbply&lhieCtiOn Wells:,,)n addition to sending the form to
13a.Yield(gpm) ) {l_: r Method of test: the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:�5 1 I t� ! Amount: t- Q�', )(' ') completion of well construction to the county health department of the county
` where constructed.
Form G W-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

veiller Self-dtrosit Corifficadon
dttkiit
New
Pe�xtjl:
I'herebycertify that the above referenced we 1 Wag grouted in appearance in accordance with
all Coumty Well rolm
Certifca e*: 9 I Date Gn &,5_-- —
construction:
Taff ; 305 Ty S'rrot.r f
Casing Type: V C, Thickness: Y�I YJ d
Casing Deft: 1-1 - Depth: . c 7Q.
L an : 1
tTcd
Height:
Drive Shoe: _
GPM: