GW1--06037_Well Construction - GW1_20230920

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: •
Rex Meadows 14.WATER ZONES
i f
FROMTO DESCRIPTION
Well Contractor Name ft. ft. 1
2113-A ft. R. 1 I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THE NESS MATERIAL
Clearwater Well Drilling Inc_ R. ft in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft in. I
List all applicable well construction permits(i.e.County.State,Variance.eta) ft. R. In.
3.Well Use(check well use): 17.SCREEN 1
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipat/Public R. ft. In.
Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R. ft. in.
Olndustrial/Commercial OResidential Water Supply(shared) 1&GROUT 1
FROM TO MATERIAL , IEMPLACEMENT METHOD&AMOUNT
❑Irrigation ft. ft.
Non-Water Supply Well: R i
R. .
❑Monitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL . EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft
❑Aquifer Test OStormwater Drainage
R. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/reek type,grain size,ere)
❑Geothermal(Heating/Cooling Retu`n)n ❑Other(explain under#21 Remarks) D R• Q 5 n. /�/�`� r
4.Date Well(s)Com eted:1 lY-%Well ID# Iftt. ` `��f\f t 111J 1 t�,iinct'
.ik
5 VellLocation: 6_/V6A ce l (C7 R. R: J
lM 6 1 tJ Ul Jif) R R i__r"!111 if r''rn
Facility/Owner Name Facility MI/(if applicable),� ft. ft. It 6 .@,... / V L.9.....,
Mcn4rea i beet M,4i . R. R. I SF P 9, A 2Q73
P steal Address,City,and Zip 'f 21..REMARKS
Linea-CI Yee , v iF v^i4r"$:ie}it iaf^:S a ?4 Liu':
County Parcel Identification No.(PIN) I M-r1''d0(3
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2e.Cer frcation:
(if well field,one lat/long is sufficient) r '
e 35' 3- 30 N SO iR �(S" W ,,----------- ' 1 -fig -ate
S• t�fCertified Well Contractor Date
6.is(are)the well(s): Permanent or ❑Temporary By signing this foamI hereby certh.that the wells)a s(were)constructed in accordance
try \\ �t with I5A NCAC 02C.0100 or 15A NCAC 02C.0209 IV 11 Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ilo copy of this record has been provided to the welt owner.
If this is a repair.fill out known well construction information an explain the nature of the
repair under#21 remarks section or on the back ofthis fornL 23.Site diagram or additional well details:
�1 You may use the back of this page to provideadditional well site details or well
IL Number of wells constructed: 2_ . `� 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: (t't.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 00'and 2t 100') construction to the following:
10.Static water level below top of casing: (ft) Division of Water Quality,ilnforma'on Processing Unit,
Ifwalerlevel rs above casing use"+" 1617 Mail Service Center,Raleig ,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to send" g the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(Le.auger,rotary,`able,direct push,etc.) Division of Water Quality,Underground jection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleig ,NC 27699-1636 •
13s.Yield(gpm) Method of test: 24e.For Water Supply&Injection Wells: In ddition to sending the form to
the address(es) above, also submit one copy this form within 30 days of
13b.Disinfection type: Amount completion of well construction to the i county ealth department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013