GW1--06329_Well Construction - GW1_20241022

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: r
Rex Meadows 14.MATERZONES DESCRIPTION
Well Contractor Name ft, R•
2113-A ft. ft. I
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(If applicable)
FROM TO DIAMETER THICKNESS jl MATERIAL
Clearwater Well Drilling Inc. / it 7 "• 0%.?in I /DW
Company Name 16.INNER CASING OR TUBING(geothermal cldsed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit ii: ft. ft. 111.
List all applicable well construction permits(i.e.County.State.Variance,etc.) ft, ft. In.
3.WelI Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER
SLOT SIZE THICKNESS MATERIAL
ft. ft.
❑Agricultural ❑Municipa)JPublic
OGeothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in.
0 Industrial/Commercial ❑Residential Water Supply(shared) 18'GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation / ft. ,0 R. ee izgv-- VniU�
Non-Water Supply Well: ft. ft ����
0 Monitoring ORecovery •
-
Injection Well: - rt. ft.
DAquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK(If applicable) I
-FROM I TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft. I
❑Aquifer Test OStonnwater Drainage ft. ft.
❑Experimental Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTIONScolor,hardness,son/rock type.grain she,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) �/ ft' 55� R• ,S'afia/ y'4 Vif 7/�
4.Date Well(s)Completed: 9 1/ �(�well II)# `�7 R 7,D D• g!air
670n. y7/ It "4-eI
58.Well Location: ft�� ;' ft. ����-P
Al LI � JScni( f ft.
Facility/Owner Name BFacilityID#(ifapplicable) = '`./
R.
3Y9t) Ii�n Ta gel. t_f- ll fL ft. 11.c.. r�. , •0 1 _�
ft. ft I� 1
/ i n 6� A
Physical Address,City,and�Zip
] .. �) �� 21.REMARKS lJ'I• ' S ['
County Parcel Identification No.(PIN) I G',i,;` .2,a
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.C rtili lion: •
(if well field,one leUlong is sufficient) / 1J�/ ,��
` �' r I 44� N Sa s `3S W �,_ ;/ r Cfk/
Signature of Certified Well Co ctor Date
6.Is(are)the well(s):XPerntanent or DTemporary By signing thus form.I hereby cerd,that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200(Yell Construction Standards and that a
7.Is this a repair to an existing well: DYes or )26o copy of this record has been provided to the well ovine{
If this is a repair,fill out known well construction information and explain the nature of the
repair under#1I remarks section or an the back 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
8.Number of wells constructed: construction details. You may also attach addit'onal 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: C5-0 (ft.) 24a. For All Wells: Submit this form with n 30 days of completion of well
For multiple wells list all depths it-different(example-3@200'and 2(3100') construction to the following. '
10.Static water level below top of casing: (Y (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6/u (in,) 24b.For infection Wells: In addition to sending the form to the address in 24a
/�/, / above,also submit a copy of this farm within 30 clays of completion of well
12.Well construction method: ! O7J 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 27699-1636
13a.Yield(gpm) s6 Method of test 4 24c.For Water Supply&Injection Wells: I i addition to sending the form to
�/ 1' the address(es) above, also submit one copy 1of this form within 30 days of
13b.Disinfection type:(91.1 J,1L Amount: 7fl art' completion of well construction to the county health department of the county
where constructed.
Form GW-r North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

c-'1761111 Miler Selifidirout C4wir31kon
/),
Owner A ihite L i. , c i i-/ e/d Norwell: V :
,.i, ./71 . Rdra Repair
PetirlitL./4i_._16_._.5-ih..._11A./.'e ._.____.
. ,
. .
, .
i hereby certittliatthe above referenced well was grouted in•appearanceln madame with ,
all Canty well rale&
Well 7 1 ,
•
Cernaiteit c;?//3 71 noKarouted: ---P-af4 . .
. • - I . ..
. ,
construed.= Gnu: - .
TO Depth: . .505
. ,
TYPm......„............. .
Casing'rpe ,PVC
easingDepet g e7 Dela: .
Dime= 4, 17 F ,
,. .
. ,
withltentick_.,........„ !, .
sift, _
, .
Drive Shot
.
. ..
i:
1
1
, .
. .
; I
. 1
.. . i" . .
! . ,