GW1-2023-01114_Well Construction - GW1_20230126

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WELL CONSTRUCTION RECORD
Thty f.,.m can be jscd R,rsinglC Or mnit(pleWClls. For tntcmal Usa ONLY;
1•Well Contractor Information: Il
Rex Meadows i4,wATIIR ZO1V8S
Well Contractor Neme FROM TO I -
DS9CRIPTIoN
2113-A ry• ft. f
NC Well C.ontmctor cer+ifiention Numttcr
1&40UUR CASING rmcttleased1:Clearwater Well Drilling inc. FROM To "�' °R1•'� � AT -
lt1AMETER TAICKNIigg MA�?t6RtAL
Comptny Natno fr. R t
z.Well CA CaR
MnstrnctnPnit G. © O tRMRTo MAIN
Rppcahlr,trll enaftcailpm mtda
(fie Cotn,t�z Stgr4 trarlanc etc,) tt• 7iiICICN&44 MATt2R1,tL
in.
3.Well USe(ebeek well use)t R• tt, is
Water Supply Wen: I .SCRI M
QAgticulnlral FROM a.. TO DIAMETER BtATSr?g TiiiCtCNfi�4 MATERIAL
❑Monjcipal/PubGc
130c0thennal(1-ieeting/Cooling SupPly)❑industrial/Cm nercjal �eidettie]Witter Supply(single)
ft. R• JTM
Mai lion OResidentiat Water Supply(shared) t&GROUT
FROM To IyOMWater$R Iy ft. ft. MATSRtAL SMP1,ACgMgNT MB7ROD@AMOIINi
Well: `
❑Moniroring PP ,
Injection Weil: ❑Recovrry n• tt_
ElAquifer Recharge it. It
❑A 1Ximundwater Remedial 19.8ANDlf;rRAVBL PACK 1} c
qu iferSrorageandRecovery UAquiferTest L7SalinityBarrier RnOM g, TO MATERIAL,,
BMPJ ACEMENT M91nour
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13Stormwater Drainage
l3r-VOlitaentalTechnology OSubsiderleaCiatil
i7Geothennal(Closed Loop) OTrscer 20.DIIILL G LOC aMae6:ddlttoartl s irtll gCreothertttal Heatin Cooliq Retttm pother lainunda#21 Remarks FROM To Dfi9CRiPTION mtar m coalman na ett
t -•7 � n
4.Date WeLJ(s)Completed: 0. ft
Sa.^'cJl lwrcsttGtn:
• 1--t•J�LL1���
20 p litylOwncrAtsm� R tl.
.� rhollityJDll(ifaPPltcnhlc) 'p
PhySteal Address,city,aaa Zip
21. BMAWCS
2 t*,
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Calmly
J�aecl identificalion No.(PIN) YSS '
56.I.atltade and Ltingltude in degt et4lfifatlfeslsemtrdy or decimal d .
(iftvell field,one lat/lon effees.
t gnsutticicm) 7-Crrtitl lion:
4,1s(are)thewell(s);A.
Signeolreoft-allied Well Centmctor/�rent or QTemporary bete`--`--
7•is this a re
ai Bill T;gwirg rhk fora,.r hcrehv evillpi.char Ilia i+eN(sj net(rlcrc)e»»a1171tted in accmrlm�rc
P r to an existing wea pyeS or �o Wth t SA NCAC 0 C.0100 or 15A NCAC 02C;0?nD rYe)1 Ca,zrtrnctinn Syandait? and tlMr n
llhly is n,cpq/r ill mq hnnntr cgnttnreAnn i„Jo,mgtlga a„d erp/af„the,rrmme nfnc�
rr7Mir rmde,'#dl rnMnrdx eectlrur nrnatbe hack r moor farm. `D�'nfrhds,rcm d lazy hers P,•rnidrd to the nrii rr1191g,
8 No 23.Site diagram or additional well details;
Fn,•Mrdrlp/c la/
ether ofwelLa construeted: You may use the back of this page to provide additional wail site derails or wet!
pna-Wme,•s the sa,nc Qonrrgzyian,
.yahur nnrfe COnStluctlon details. You
,�pp)y
rn, )!s ONLP auh may also attach additional pages if nec ryessa
yuacn„ ,
?•Total well depth bdo�y land sn A'�� SUBMi ML INSTUCTIONS
Far aurlrlplc ue1h xi,all(l rfaeee—
"nrizy!fd/Jla+rnr(crcmn),fo-3@20n and2(r, 10 ) (Ili 24a.EI A11 VN0a: Submit this fornr Static water level below top aPc w(thin ao doy8 of completion of well
construction to tlra foilowing:
D. as}trg: I f
1"n7,rrrlrrc/lsahmkigsyn1Mrnc'•+'1 (ft) DivisionofwaterQual(ty,lufplrjiaBRR
$orehale diameter: I g 1617 Mail Service Center,liar' pro Dg Unit,
rn) gh,NCz76"4617
?fib.For In actin .Ij r J 1 12,Well construction method: n addition to sending the form to the address in 24a
(i•c auger,rotary,cable,direct push,etc ahovq also submit a copy of this form Within 30 dal construction to the fonowitlg. S"r of completion of well
FOR WATUR gt)PPLY WELLS ONLY: Division of Water Quality,Underground tnjeeNon Control Program,
13a.Yle}d(gPm) ?0 n 1636 114811 Service Center,Ralelgh,NC 27699-1636
Method of test: t�1 24e o I
Water StlDDiv Injection Welt-I t
"Ill Disinfection typC the addrees(aa)above,also submit one addition to sending lire form to
Amount: completion of well conStnrctian to the coin'of this fool within 30 days of
FmmCgtt ovbcmConstructed. �t5''health department of the county
North Chmtina Denn.t-----0 __:_ �

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Well Drlllor SoWomut Cerdfkadou
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Ne�n��VlTell: �'
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i hereby £Y tliat the abm rdeme�cecl wed waygmiod in
all Coum Welt rulesSign
Wei filer.
DGroubed' -
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Consh udiow.
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Tot Type: -
G Thiclmess:_
Cagng'rilpe:: -----� Dp :_ �v
Casng
Diameter.
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Drive Shoe:
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