GW1--04914_Well Construction - GW1_20240816

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can Ds and for single or multiple wells
1.Well Contractor Information:
Rex Meadows 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2113-A It. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(If applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. I it. Le I it. in. lt W„1/ (Si-eel l -
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. n. In. -
List all applicable well construction permits(.e.County.State.Variance,etc,) —
It. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: i FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. R. in.
❑Industrial/Commercial °Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
°Irrigation 1 ft ° «. nn� i nI� -,1,1LC/ n j
Non-Water Supply Well: « « ( [r
❑Monitoring ❑Recovery
Injection Well: • R. ft.
[Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(If applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Storage and Recovery ❑Salinity Barrier (t «.
°Aquifer Test °Stoimwater Drainage rt. «
°Experimental Technology ❑Subsidence Control 1
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) °Tracer FROM TO DESCRIPTION(color,hardness,soli rock type,grain size,etc)
°Geothermal Hearin Coolin Retum °Other lain under#21 Remarks) R. ft.
ft. rt.
4.Date Well(s)Completed: -22 rZ ell ID#
rt. ft.
Well Location:Moi1
Facility/Ownneer} � (� �r�Name Facility lD#(ifapplicable) ft. « k cl ` .
Phh ical Address,City.and Zips o zi.ItE......-1....---------.—• — .— AU kl_- 02�
l;-Acorn f n
County Parcel Identification No.(PIN) 7
ITsf3-t.i.,�h� ; .'IkY
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 e titication' �—
(If well field,one tat/long is sufficient)
• ' t-At.o t a�lI N ' �5' � W -1- )et-)-U
i �.. Sig edified Well Contractor Dale
6.Is(are)the well(s): Permanent or OTemporary By signing this form.I herein.certtly that the%riffs)was(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 (No copy of this record has been provided to the well ouster.
If this is a repair.fill our known well construction information an explain the ranur of the
repair under a2I remarks section or un the back of this Atm. 23.Site diagram or ad!ittivaat:r rli dd4:riu::
You may use the back of this page to provide additional welt site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
M .,,r .,«.::r:N SIl!4ai. rI.A.1,!tiSTlt{"rtt)yt
(1,TeMI well rlonth holnw lend etwfsee• 4 4 5 fft-1 24a. For All Wells: Submit this form within 30 days of completion of well
Fin multiple we-Ilt list all depths ifdiffereat(example-351200'and 2(d1001 construction to the following:
in.F11!M wa:.•t 'eve:s-mu.w ton Ri casino: LDO 12t., r.: .,:t::,.,_ -, �t.d ,_--,1 -vee.4..ti!_-rt,
_
1/.WIC(.CYC....Mw•C CY..M6.Mac •
•,...__ -.. - •, • •.. Go. ... ._.-_���.
'' Anit
•
I.Rorrlmlr di#meter! k v `S _tie_) 24b.For Inlpron Welk: In addition to sending,the Corm to the address in 24a
_, ,,, .r ,z VADACUNr•nmM!rhnn to tftr?..^.itnwrns,
(i.e.auger.rotary,cable,direct push.etc.)
3) --- --- - - -.. - - -- _-
I.__ _.. _.. • .. _. . �,� ! ><4.- Ln.W_fa.Q-., . .f ..:let:+..:ll?art- ':.!.: :.tact to Az....I'nrn:'
1--� - --- -------- • 1 the addresslesl above, also submit one copy or tens roan Wltnln eta OW or
l S Un IS a,.f eftnn hmn. ,.....ant, 1 compIC11Dn Ut Weil GOn'lruutiuts lU the CUtiliiy i teniiir ticinutnteiil toil iltc tznu«y
Conn 4W-I woos t.arututa uepartweut tar tnvaunntent gnu is arum ttewtuces—utvbwn at water,luatuy mks.......,eta.GU u

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I hereby Gel*t a the*Ave r oed NVell vs; in sia aooa+donaevah
all Court"We roles.
wen renter Ar Mect,O,DUDS
Catificalec 11 -fir _ Dq Grau . '7 2 2 ;)L
Construction Cider
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