GW1--04951_Well Construction - GW1_20240816

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
I.Well Contractor information:
Rex Meadows 14.WATER ZONES
PROM 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 applicable)
FROM TO DIAMETER THICKNESS MATERIAL Clearwater Well Drilling inc.
j ft. (-.1 R. Lci t{'x' in.
Company Name 16.INNER CASING OR TUBING($:othermal closed-loop) i J)(
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: U. ft. in.
List all applicable well construction permits(i.e.Count State,Variance,etc.)
ft. ft. 1E4
3.Well Use(check well use):
17.SCREEN
Water Supply Well: , FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑Municipal/Public it. ft. in.T
❑Geothermal(Heating/Cooling Supply) Xtesidential Water Supply(single) ft. ft. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18•GROUT
❑Irrigation FROM TOMATERIALr�ATERIAL EAIPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: f. 0 it
e r Mtn*
1 M t Ci
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft. j
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft. —
DAquifer Test ❑Stormwater Drainage
DExperimental Technolo ft. ft,
gy ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑GeoUtertnal(Closed Loop) OTracer
FROM TO DESCRIPTION(color,►atdoeu,soil/rock hpe,grain size.etc.)❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ( I 1 it, 1 `
, a
4.Date Well(s)Completed 1-ZL` Well lD# ft• alto n. C�1�,AC-
Sa.Well Location:
� f to ft. ,'� ft. s. >��1�
1-` t C-Gr re s Lici l-) l ft. S ft. ���r,' U
ft. H. tc1
FacilityiOwner Name Facility 1D4(if applicable) _
ft. H. ---T-•-�n
I N\Parkfl STUt On Rd. _
rt. rt. _�.ti * 1..,-..
Physical Address,City,and Zip Mar
r-C Oj Tn
1 ���( ss:�� `V (�lA L7 21.REMARKS A 1 i Lug.•
County 1 Parcel Identification No.(PIN) ) —
;r
5b.Latitude and Longitude in degreeslrninutrslseconds or decimal degrees: 1a�++
(if well field,one laUlong is sufficient) Z2.Ce 'fication:
)
�' : ' �* 4 N S. a 4a gas W --t--- 7--.23-t q
` / S of Certified Well Contractor Date
6.is(are)the well(s): Permanent or ❑Temporary
/// ��\ Bp signing this form.1 1hereby mriif that the.7211g arts t++Yre)mnstrmved in accordm,re
willr ISA NCAC 0_ he0 o•I5A NC'AC Downer.
R�fl Conslruclian Stm,danls mud that a
7.is this a repair to an existing well: ❑Yes or �Vo
t,(� copy of this record has been provided to tr:Q well nutter.
if this is a repair,Jill out knovvr n'ell construction information a Yplain the nature of the
repair under#21 remark section or on the hack 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
R.Number of wells constructed; constnictitm derails. You may also attach additional pages if necessary.
For multiple injection or non-troter supply wells ONLY with the same construction,you can
submitonererm' _ ` , _ SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: J 7`,� (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ij di/Jcrcnr(eventide-3(d200.((and?(f 1001 construction to the following:
lJ
10.Static water level below top of casing: C (ft) Division of Water Quality,Information Processing Unit,
filmier level is above casing.use-- ' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: l0 ` (p,) 24b. For Injection Wells: In addition to sending the form to the address in 24a
t _�y 1 above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: [ ( 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 2 7699-1 636
1
13a.Yield(gpm) t) Method of test: net 24c.For Water Supply&Injection Wells: in addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health depamnent of the county
13b.Disinfection type: Amount:
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality
Revised Jan.2013