GW1--06158_Well Construction - GW1_20230922

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells -
1.Well Contractor Information:
-
... .. I . .
Rex Meadows 14.WATER ZONES - 1' • .
FROM- TO DESCRIPTION .
Well Contractor Name R R•
211.3-A . • rI• ft. I I .
NC Well Contractor Certification Number IS.OUTER CASING(for multi-eased wells)OR LINER(if ap likable)
' FROM TO DIAMETER THICKNESS DIATERiAL
Clearwater Well Drilling Inc. .ft. ft• in.
Company Name -16.INNER CASING OR TUBING(geothermal clasedlloop) - •
FROM TO DIAMETER THICKNESS 11LiTERIAI.
2.Well Construction Permit#: . - • ft. • ft. in. . —
List all applicable.well construction permits(i.e.Coumy State.Variance,etc.) ft. in. -
3.Well Use(check well use): 17.SCREEN. .': . : •. - •
Water Supply Well: • FROM - TO • DIAMETER SLOT SIZE THICKNESS MATERIAL
['Agricultural ❑Municipal/Public ft. ft. in.
Xteothetmal(Heating/Cooling Supply) ❑Residential Water Supply(single) D• ft. io.
❑Industrial/Commercial ❑Residential Water Supply(shared) is.:GR°UT - -
FROM TO MATERIAL EMPLl10EME�2,T METHOD&AMOUNT
❑Irrigation . ft. ft. 1
Non-Water Supply Well: .
❑Monitoring ❑Recovery R. ft.
Injection Well: - - ft. R. I
❑Aquifer Recharge • °Groundwater Remediation .19:SAND/GRAVELPACK(Iffapplicable) • .- ..I.. •: . .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO . MATERIAL ,- - EMPLACEMENT METHOD
• ft ft. I
❑Aquifer Test ❑Stormwater Drainage
ft. It.
❑Experimental Technology ❑Subsidence Control '20.DRILLING LOG(attach additional sheets if necessary)" •
OGeothermal(Closed Loop) ❑Tracer FROM. TO DESCRIPTION(color bardtiess,solrro k type,grain srie,ere.)
❑Geothermal(Heating/Cooling Return) °Other(explain under#2I Remarks) 0 ft• 35D rti CO. ,
.iift. ft• CSIXV ld
4.Date Well(s)Completed' -aq-X3 Well!D#
shed 1( OG�tI.�(WILS ft. ft.
5 Well Location•.
It. r`
1�)CAC 0 76NO ft. rt.
Facility/Owner Name n Facility iD#(if applicable) . V`� "R"e w" ,."^^
�Z• ���� I�I1�Je_ e Qu.c'i1M&rsha.QJi rt AddressCity,andZip IV•G 21.RE iMARKS f•4 - �Fr• dy �O+-'tyZJ-
1lt/""50O irlkcct shall Pena( ,.� a II
County Parcel Identification No.(PIN) D1�'C•r J43
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 1 •
(if well-Geld,one lat/long is sufficient) r
•Ce lii lion:
S for )OD N 4S313 W
.,4.,------1.--- 9 -3-93
Signal ofC • ed Well Contractor Date -
6.Is(are)the well(s):`ikermanent or °Temporary By signing this form,I hereby corm'that the wrP(s)was(were)constructed in accordance
` with I SA NCAC 02C.0(00 or ISA NCAC 02C:0200 Well Construction Standards and that a
7.Is this a repair loan existing well: ❑Yes or )lo copy of this record has been provided to tire imll owner.If this is a repair,fill out known well construction information an�l((e`r`plait the nature oldie
repair under#21 renle&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
8.Number of wells constructed: 3� construction details. You may also attach additions pages if necncsaty.
For multiple injection or nun-water supply wells ONLY with the same construction,you can I
submit one form. SUBMITTAL INSTUCTIONS 1
9.Total well depth below land surface: .. - (IL) 24a. For An Wells: Submit this form within 3 days of completion of well
For multiple wells list all depths tfd�ercm(example-3G00'and 2®!00') construction to the following:
10:Static water level below top of casing: (ft) Division of Water Quality;Informatio Processing Unit,
limner level Is above casing use•'+' 1617 Mail Service Center,Raleigh, 'C 27699-1617
I I
11.Borehole diameter: • - (in.) 24b.For-Iniection Wells: In addition to sending the form to the address in 24a
above,also submit a copy of this foml within 3 days of completion of well
12;Well construction method: • construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: • 1636 Mail Service Centi r;Raleigh, C 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells: In a ition to sending the form to
the address(es) above,also submit ohe copy of is form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality] Revised Jan.2013