GW1--04880_Well Construction - GW1_20230728

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WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
I.Well Contractor Information: I
Rex Meadows 14.WATER ZONEI
S DESC
FROM TO DESCRIPTION I
Well-Contractor Nameft. ft.
2113-A ft. fr.
NC Well Contractor Certification Number IS.OUTER CASING(for muiti-cased wells)OR LINER(if ap liable)
Clearwater Well Drilling Inc. FROM ft. TO ft. DIAMETER I ITNICKNFS4 MATERIAL
in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit it: i4 ft. Ice I
List all applicable well construction permits(i.e.County.Stale.Variance,etc.)
ft. ft. in.
3.Well Use(check well use):
17.SCREEN I
Water Supply.Well: - FROM To DIAMETER SLOTSIZE THICKNESS MATERIAL
°Agricultural ❑MunicipaUPublic R• ft. ta.
°Geothermal(Heating/Cooling Supply) tesidential Water Supply(single) R• B• in. I
OlndustriaUCommercial °Residential Water Supply(shared) 18.GROUT i
°IrrigatioII FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: tJ R' ft. I p Mail n' 4
°Monitoring °Recovery ft. ft. �``(-`n u_l t�
Injection Well: ft. ft. riJ�+
['Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK(if appRabte) I
°Aquifer Storage and Recovery °Salinity BarrierFROM TO MATERIAL I EMPLACEMENT METHOD
°A uifer Test it. ft 1
q °Stofmwater Drainage
°Experimental Technolo ft. R•
gY °Subsidence Contra!
OGeathermal(Closed Loop) pTrac� 20•DRILLING LOG(attach as d�ttionnaa9 sheets�aeccssary)
2 &A ON( �cI r-1-tfrock ttpagrdnsize,etc)
OGeothemral(Iieating/CooGing Return) °ether(explain under#21 Remarks) R• R, }/).
4.Date Weil(s)Completed:Le-lt p�3 Well 1D# (-La D• r"J R• �1�, /1,Jt iL
/�f�Se.Well Lotuttion: Ut-' f. ior
'� L y word ; it. S.ft. or I
rSf��r I rUld c ft. ft.
Facility/Owner Name Facility ID#(if applicable)
P)Prr Ih ll Mt�(s�h ll �)� It, ft. I it:� :01t1)
R. >Z•
Physical AddrFss,City,and Zip r ' r
� ��0� 21.REMARKS 1 iiiL 2 O 2023
I r;�,,,,a,; ;l''s•"•^4--'S.'"m 1 fttft
County Parcel Identification No.(PiN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: }r0
(if well field,one' latilongsjsufficient) 22• er'fication:
'3 M is` N 0¢a aq• 1 �1 W -' .-- -' (k.-4 -c)-3
Si of Certified Well Contractor Date
6•Is(are)the well(s):permanent or °Temporary
By signing this form,i hereby carte that the well(s�was(were)rnnstnicted in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200I ifell Construction Standards and that a
7.Is this a repair to an existing well: °Yes or tlo copy of this record has been provided to the lie awn Obis is a repairfdl out known well construction information an explain the nature of the
repair under 1121 remarks 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
8.Number of wells constructed: construction details. You may also attach additional 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: 3(Y 5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths"different(erample-3@J200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Quality,Inform lion ProcessingUnit,
if water level is abate casing,use"+•
ff t�'�1/ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: W l" rl) 24b.For Infection Wells: In addition to sew `ding the form to the address in 24a
l,/3�.'�f above,also submit a copy of this form withi 30 days of completion of well
12.Well construction method: 11 construction to the following:
(i.e.auger,rotary,cable,dweet.push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: /� 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of test: RI V 24c.For Water Sunniv&infection Wells: Ini ddition to sendingthe form to
/��( r/� p [, '� the address(es)above, also submit one copy f this form withi 30 days of
13b.Disinfection type:C iOt 11lJt Amount: 4.Kell completion of well construction to the county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013