GW1--04909_Well Construction - GW1_20240816

WELL CONSTRUCTION RECORD
This form can he used for single or multiple wells For internal Use ONLY:
1.Well Contractor information:
Rex Meadows 14,WATER ZONES
FROM TO D69CRnrnoN
Well Contractor Name R. ft.
2113-A ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(far multi-eased weE.)OR LINER(if sp*ileable)
Clearwater Weil Drilling Inc. FAOM TO DIAMRTSR THICKNESS MATERIAL
lft' tit. 1 u '}i5 in
Company Name 16,INNER CASING OR TURIIN�G(geothermal dosed-loop) '�VC
2.Well Construction Permit#: r U��" — DOI L FROM TO ER THICKNESS MATERIAL
List all applicable well construction permits(i.e.Cmrnry,Slaw,Variant.,artft' fL in..)
3.Well Use(check well use): It. rt. —In'
17.SCREEN —
Water Supply Well: FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL
(Agricultural °Municipal/Public ft• ft. fa.
❑Geothermal(Heating/Cooling Supply) (Residential Water Supply(single) ft rL la.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROOT
FROM TO MATERLA,L EMPLACEME
NT METHOD&AMOUNTC11TtgatiOn I n. (-)I7J ft.
^ { Vnt- rib.)(F -1Non-Water Supply Well:
❑Monitoring DRecovery ft. n
Injection Weil: ft rt.
°Aquifer Recharge ❑Groundwater Remediation ' 19,SAND/GRAVEL PACK(if appHcabk)
°Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERFAL EMPLACEMENT METHOD
❑Aquifer Test ft. ft.
QStonnwater Drainage
❑Experimental Technology QSubsidence Control ft. ft. 1
❑Geothermal(Closed Loop) ❑Tracer 211.DRILLING LOG(attach additional sheets if necessary)
PROM TO j DESCRiPTION feeler,hardness,x+thoea pram etas,etc,)
❑Geothermal(Heating/Cooling Return) °Other(explain under#2I Remits) ft. ft' 1 + ci. V
1 I� :� �� a1��
4.Date Wed1(s)Co leted1 _3_(�.Well lD# 11F) y'\ 1 ft' -7�11\/- ,
Sa.Well Location: r( �.t O t l �( 4 c, it- L—`5s ft- �(�"{,X/l�(v.
Jt^u'��h ��►'�m�ns r ci y-`ic f>- ,--3LIS-n. : e 1-t
Facility/Owner ft. n•
Facility i V(if applicable)
2 rt.
s al Address, ft. ft.P
M!,t� City,and\Zirp
),r `tYf`I� 11 aC -. 21.REMARKS _ ve r
County Parcel identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: ++
(if well field,one latllong is sufficient) 22.Cer Deaden:
)- Li-a),� N , Si d�g
6.Is(are)the well(s):*ermafent or °Temporary Si are of Certified Well Contractor Date
Rv signing this form, 1 hereby certi15,that the,rell(.sl nos(„ere)rnmrnecterl in accardanre
7.Is this a repo([to an existing welt ❑Yea or o with 15A NCAC 01C.0100 or 1 SA NCAC 72C.0200 Well Construction Standards and that a
1(thls is a r cello'of this record has been provided to the well owner.
cpair,fill one known well construction Information and explain the nature of the
repair under#2/rernarlrs section or on the hack of this front 23.Site diagram or additional well tietails:
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 ne cessa
For multiple infection or non-water supply wells ONLY with the same construction you can ry'
.rnhmit one form, SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: ES Ll"-,,,. (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For antitank,wells list all depths if different(example-3®200 and l 100'
C� ) construction to the following:
10.Static water level below top Messing: (OD (ft) Division of Water Quality,Information Processing Unit,
Jf'water level 1s about.casing.use^+ 1 R 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: v 00 24b.For Inlecdon Wells: In addition to sending the form to the address in 24a
m L/y N above, also submit a copy of this form within 30 days of completion of well
t `,
12.Well construction method: 1 OJ construction to the following:
(Le.auger,rotary,cable,direct posh,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center.Ral
eigh,NC 276994636
13a.Yield(gpm) L\' Method of test 2ii&i 24e.For Water Sltooly apt tLtlectjplq Wells: jn addition to sending the fomr to
— the, addresses) above, also submit one copy of this form within 30 days of'
I3b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

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