GW1--03664_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 DFSCRIPTIO
Well Contractor Name ft. fL
2113-A ft. ' ft. —
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER Of applicable)
Clearwater Well Drilling Inc. FROMJATERIAL
ft. TO ft. DIAMETI R(Lin. THICKNESS —
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2-Well Construction Permit#: ft. ft. is
List all applicable well construction permits(i.e.County,State.Variance,etc.)
—
ft. ft. is
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
OGeothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. it• in.
Olndustrial/Commerciat ❑Residential Water Supply(shared) 18.GROUT
FRO\t TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation \ rL c9C ft. 0.Q. 11n-\" �� 6u 6
Non-Water Supply Well: ,
❑Monitoring ❑Recovery it it
Injection Well: ft. ft.
[Aquifer Recharge [Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
[Aquifer Storage and Recovery ❑Salinity Barrier rt. ft
[Aquifer Test OStonnwater Drainage
—
ft. ft.
❑Experimental Technology [Subsidence Control 20.DRILLING LOG(attach additloal sheets If necessary)
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,tawdsrm,sallfrock rapt,grain size,etc.)
OGeothermal(Hcating/Cooling Return) ❑Other(explain under#21 Remarks) , It. IA as fL &I y y r,a-CAA' r�
4.Date Well(s)Completed:5-2 ` ` `` ell ID# t 1 R• 5 t L ft- rel K1 �l ( i�
Sa.Well Location: 5 i Z ft- 5.i 3 ft. _AS, Ck
. cO�,,L.� 1..i n \;r� \\).6\ es\e ( �I ft. n-
� R. R. ... -f
�1 Facility/Owner Name Facility IDs(if aapp licable) ft. It.
r .`-�L..? v E D
T7 C v )\-\iiu 1 . a-VS W{1 1 14)3 R. ft JVN 1 8 2024
Physical Address,City,and Zip 21.REMARKS
NlrAiscit ) irk.):f••"' •
County Parcel Identification No.(PIN) '
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 27-rCerti cation
(if-well field,one latllong is sufficient)
?)`.' uq ' 31 N O' .3a' iCq W ., __ _ 5-K)Z9
����,tutt� Signature of Certified Well Contractor Date
6.Is(are)the well(s): permanent or [Temporary By signing this form.1 hereby cerl/,that the nent's,was(were)constructed in accordance
with 15.4 NCAC 02C.0100 ur 15,4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ffio copy of this record has been prorid.'d to the well owner.
11 this is a repair.fill out krronn well construction information and explain the nature of the
repair under 021 remarks section or on the bock of this form. 23.Site diagram or additional well details:
You may use the back of this pa;e 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 land surface: rJ (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijfdiifferent(example-3(200'and 2gf!00') construction to the following:
10.Static water level below top of casing: 1 Q1 (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,rsc"+" 1 t_ 1617 Mail Service Center,Raleigh,NC 27699-1617
Service11.Borehole diameter: P I V (in.) 24b.For Injection Welts: In addition to sending the form to the address in 24a
( (�� above, also submit a copy of his form within 30 days of completion of well
t 12.Well construction method: LcC. ( construction to the following:
(Le,auger,rotary,cable,direct push,etc.) -
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY�W ELLS ONLY: /� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) `1" Method of test: vt 24c.For Water Supply&Injection Wells: In addition to sending the forth to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:c1 ,1 t/t`tV. Amount: w Cil af) completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013

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wen Driller
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