GW1-2023-01133_Well Construction - GW1_20230126

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WELL CONSTRUC.",l►ION RECORD
Th` +canoeusedfarsingteormuinpla Wells. For lntemal Ilse ONLY:
1•We"Contractor Information:
Rex Meadows
U.wATERZDA22 i
wen Contractor Name FROM TO D1(8CRip•RON
2113.A "''
NC Well Contractor Ccrtificntioo Number fl• 1
ClearWafer Well Drilling Inc. 1a ouTeRCAsu�c rmo d�veib flR11,IlVpR toe FROhI TO DIAMETER 7niCltNEgS MA7EWAL MA?B
CompstryName it' RIAL
6�11 Q\ i"-
2.Well Ca 1&1NNTRCA,ai Q0RT1JBlltlG rmldnedd
Construction Permit#: rROM TO DIAM6TQN1cKNfi33
/.isr all pPl licahk rte/f cnran7rdJnn R T
pe-111,(fie•Cott 0,So",1/nriancr elr.J o
R In.
3.Well use(cheek well use): >t• Ia
Water Supply WeB: 1?.St'RSEN
QAgricultnral MIN TO DIAMETER 9LOT912E TitiC[aYFBS MATBRtAL
QMunieipai/Ptblic ' B• ft, in ;
❑Geothermal(Hcating(Coolingsupply) `1 Residenthd Water•Supply(single)"Industdal/Commeroial ft. i?, In.
Water Supply(shared) M GROAT
lalrri lion FROM TO MATERIAL SuPPIY well: it CraD R.
� D AMoum
t]Monitodng fL rr_
injection WeIi: QReco very
❑Aquifer Recharge R it.
OAquifer Storage and Recave p(''fOundwater Remediation 19,SAND16MVBL PACK IF
FROM TO 0
Recovery LlSaiinity Barrier MATERIAL: SMPLACBMB t�lAquifer'i'est 13Stolmtvater Drainage D. n, NT M&TROD,
❑Txperimental Technology QSubsidence,Control it, fY,
OC'+eothe(mal(Closed!•oop) pracer 21L DRiLLMe t{DG atlaeh addl8aad adeotaltrweaa>+
i7Gcothertlral Heatin Cooliq Return QOtber lainundcr 21 Remarks t?ROM TO DEQCRiP710N wWeoeli. ate.
a.nary Well(a)completed; 1 D-�Z-Zwen iD� e
Sa.Well Location:
rocilityu wncrNara* iL fL
Taallity ID/I iifapplienhle)
` fr,
Physical Arklrrss,Cit,
Y rmd Zip K)G it
� . 21. BMARKS ^
County
. Pawl fit
SU.t.aHeade and Longitude in degrees/roinntealaeconds or(�iflvcJltf�ie•l rf.°o n�e la�t/ton g,is�a(�u fl't o�t'cm) o decimal deffeea:g 22,C
N : r
ticalion: ;,
6,la(are)thewell(s); Mua,�m or pTcmpotrary signOfCctlificd Weil Contrnctnr ( Date ID II I
7.19 this a re R5 signing rhtc fnrnr,J hcrehr•°rr 101 Chat fhe ire/J(s)nor(irrtr)n7nalMMI1»ncctjrdnnce
pair tot an exiating'well: QYes Or 1 nfJh!SA NC'AC 07.C.01/10 or PTA NCAC 02C:0209 Il'eJl CnraNrnctinn SmrrrJordr
1mrisnrr/xrir,fJJmrrdnrnt7Jttrcllcnnshtrcrinninfarntnllnnand nthennnnrgjy/,c
r4Pnir anrler 021 renrnrkr srclJnn°rnnthe hRCknflh Mal n. eDm�'11hEr r"`nrrl/ors horn ynnfdrd 10 fhe null nttner. rtr7d Chat q
8.Number23.Site diagram or additional well details:
/r++nnrhipletnjecrins : You may use the back ofthis page to provide additional well site details or well
lc ornmr rvnter afwalla constructed.
watts ONLF-ilk rho.some eansrrneNnn.yrrn run Constmebon details. You may also attach additional pages if necessary
snhwir�nr.fnr,n.
Well
9.Total di depth 6u j SUBMITTAL iNSTUCF(ONS I +
Fnr narlrlple below
el ow rangy.9art'ace:
t if dPrrnr(ernmPlo-3{r]Zpn mut2Ut00j ED(fW 24a. Al Wells: Submit this forte within iD. 3D d
construction to(Ito following; °� °f completion of well Static water level bob
a'unrrrlrrc/irahmk � w�pof�jas: I
(ft,) Divtaton of water Quality,inforlilatlon PrOCC9,9inq Unit,
]1.Borehole diameter. t) 1617 Mail Service Center, Ory
(;n,) 9h,NC27699-1617
24b.Fbr Ins imfi 2011F. In addition to Sending the form to the address in 24
a
12.Well construction method:-��L1 rU above, also submit it co of this form
(i.r;auger,mtary,cabl PY tm %�itbin 30 days of completion of well
S direct push,etc) construction to the following:
FOR WATER SJJPPLV LVRLI S O
NLV: Divtslnn Of Water Quality,undergrouua tajecdon Control Program,
130.Yield(qpm)_ 1636 Mail Service Center,Raleigh,NC 27699.1636
Method of test: ` tt
24e Far Water Srro.,l.,p Ia •-•et1s 11 aaddition to sending the form to
]3b Disinfection type; Q the addresn(es)above,also submit one co
l y Amount: p ColRpi on of well Construction to the cout i 'oral's epa meet 30 a co Of
Faun G\ttr
whereeonstntcted. i health department of the county
Worth Cfim(ina Dcnnrrmeoe..ro....:__._ _

i
Well OdIbr self emus CerdfkaMeal i
i
i
Neiq WeU-
Addc+ess•
I hereby £Y that the abate refemenoed weld Wm grouted in appearance In, =dqAaewith.: .
all County WeRMes.
Well DrMer:
Certificate#: 2�l�j— Grooimd• I©-1— I '
Corm ucdon (knot
Fatal Depth; �� Ty�,� Ce_CYZ 1�.
Casing Thinness:. 1rYl t �C e C �
�g�►: �ace ]Deptb:
00
Wtil'
Height
Drive Shoe:
Cpw.
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