GW1--06093_Well Construction - GW1_20230921

WELL CONSTRUCTION RECORD
This farm can be used for single or multiple wells Far Internal Use ONLY:
1.Well Contracror Information:
Rex Meadows 14.WATER ZONES I 1-
FROM TO DESCRIPTION
Well Contractor Name iL R. I
2113-A ft ft. I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(flap Ueable)
Clearwater Well Drilling Inc. FROM
f. J TO ft. I t, 1n. TM► MATERIAL
C.
Company Name I ��
16.INNER CASING OR TUBING(geotbcrttialdosed-loop)
2.Well Construction Permit#: -. 70/�3 - O�I FROM TO DIAMETER TA1CICNESS MATERIAL
Ql(��{List all applicable welt canstruction permits re.Cormry.State,Parionce•eta) ft.
ft. R i in.
3.Well Use(check well use):
17.SCREEN 1
Water Supply Well: FROM TO DIAMETER SLOT SIZE I1HCKNESS MATERIAL
°Agricultural DMunicipal/Public R' H. 10
°Geothermal(Heating/CoolingSupply) Residential Water Supply(single) O• ft. In• I
Olndustrial/Cominercial °Residential Water Supply(shared) 1B.CROUT To
❑krigatioa MATERIAL EntPLACEniliht'rnrErtlOD&AMOUNT
Non-Water Supply Well: I IL 20 if' Ce el. r.i EMPLACE:,
[Monitoring °Recovery ft• it.
Injection Well: ft. it. I
DAquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(If applicable)'
DAquifer Storage and Recovery °Salinity Harrier FROM TO MATERIAL' EMPLACEMENT METHODrt. ft. I'
°Aquifer Test OStomiwater Drainage
°Experimental Technology °Subsidence Control a. i
OGeothetmal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if nekessary) -
FROM TO DESCRIPTION(color,hardness,soil/reek type,grain ale,err)
OGeothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) 1 R• 40 D• 3a _` �i p r-
4.Date Wells)Co�ileteed:�p j� l W/�1ID# ( tt �' R ,J1�,'p'��t`\C/�l!put-IC t
Ss.Wen Location:V01{C RocK Conc2 . (Pak !n)e (Irani-
il..ti I
&'C(�*-+- Si r q I y L�l Clft. it.'7Dt�ft. ,
Facility/Owner Name � (-1 n/} g j t �' ")
�"`11'"��,r +` i � �(ID�fl(-if applicable) I Z.:�� r 1"`�'s•i;�4'•"t
00AAC '1 M.-1-ft^1. 110:AC 1 tr' OC_.3 R. ft. S
Physical Addreessss,,City,and Zip
I " 2 �0��
L/IR.�1 c_ 1 2L REMARKS i
{ ' I 1r a�rrr awl,., t Irv::j Lit
i laA~Hl( i County Parcel Identification No.(PIN) I
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: ,Celli don:
Orwell field,one tat/long is sufficient)
35• s 33r2 N $a a3` 3Q10 w t�� I-1 4--oR 3
S' t Certified Well Contractor Date
6.Is(are)the well(s):Ytermanent. or °Tern o1.
p terry 8y signing this form,1 hereby Certify that the wells)IL(were)constructed in accordance
with 15.9 NCAC 02C.0100 or 15A NCAC 02C.0200 i Construction Standards and that a
7.Is this a repair to an existing well: °Yes or ONo copy of this record has been provided to the well owner.
If this Is a repair,fill out known well construction Information and explain the nature ofthe
repair under 021 remarks section or on 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
6.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 I
submit one form. � SUBMITTAL INSTUCTIONS
t
9.Total well depth below land surface: I 0 5 (g,) 24a. For MI Wells: Submit this forth within 30 days of completion of well
For multiple wells list all depths If different(example-3@200'and 2@l00) construction to the following: j
10.Static water level below top of casing: -1 0 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+"i 1617 Mall Service Centel.,Raleig(y NC 27699-1617
11.Borehole diameter: (..121 D (i_n.) 24b.For Infection Wells: In addition to sendi the form to the address in 24a
12.Well construction method: (�1 a)`l above,also submit a copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) t construction to the following:
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Dcii
13a.Yield(gpm) Method of test: 24c.For Water Supply&Infection Wells: In a dition to sending the form to
the address(es) above,also submit one I copy t> this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
*here constructed. I '
Form GW-i North Carolina Department of Environment and Natural Resources-Division of Water Quality' Revised Jan.2013

•
Witt Mier 5al -
$ro Collifkation�
�o�iCl 1&&ck Conan- .
owner &PH- Rasing Ion Newwell-
Address: 69-L-ta-)
Posit CS8 acA 3
I hemby cell**at the above referenced wen w in appearance inaw with
all CotmLy Well Wes.
WellDriller Rex M dt) S s- �� '
cart ,cat : 0113 -4 - DatoGrou ed: -
Construction: Grout
Total Depth: "RDS Typm
Casing Type:_pVCZ- - Thickness: fi',ie a t
Casing Del& 40 at)
Minuet= COTE
H
GPM:
is
is