GW1--06171_Well Construction - GW1_20230922

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WELL CONSTRUCT N RECORD For Internal Use ONLY:
This form mote used for single or tiple wells
1.Well Contractor information
Rex Meadows 74.WATER ZONES r
FROM TO DESCRIPTION
Well Contractor Name R. It.
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2113-A ft. ft.
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NC Well Contractor Certification Nu r I5 OUTER CASING(for molt-casedwells)OWNER(ifa !feeble)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilli g Inc. 1 R.�°� et- lc1 tI $ in. C)\r
Company Name 16.INNER G OR TUBING(geothermal closed-loop)
n FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: l�a V1 H. H. . in.
List all applicablewel construction permits(i.e.County,State.Variance.etc.)
ft. B. f in.
3.Well Use(check well use): 11.SCREEN
Water Supply Well: FROM TO DIAMETER stars-me THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. tL In.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑lndustriaUCommercial OResidential Water Supply(shared) 1&"GROUT I
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation l f rye ft.
cnry1;fin, ,`I ,d
Non-Water Supply Welt
1 t)L1 J 4'J 1 1'lC l TI 1Gt
[Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(If applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
ClAquifer Storage and Recovery [Salinity Barrier
❑Aquifer Test DStormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets tfaece,sary)
OGeothesnial(Closed Loop) ❑Tracer FROM TO DESCRIPTION(caw,hardness,mWERRAlane,wain Ate,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ` It. 43 oS ft' l a l C11 -c14'C +
4.Date Well(s)Completed: Well ID# ` �� � WA9i
5a.Well Locatio : wart na rL ' IG i6
�t4X ft. 51*I
Facility/ wner Name {} Facility ID# 'fapplicable) R. ft.R. ft. �' i i rv.,
Physic•1 Address,City,and Zip 4 r (' i""s a
2L REMARKS i...�t.,i .. J n.� d
` A SEP 2 9 2023
County Parcel Identification No.(PiN)
5b.Latitude and Longitude In d greedminutesfteconds or decimal degrees: iftiOnicaticn Prcx,sWieoe,g Lira
(if well field,one lat/long is sufficient) 22.Certifi on:
3t qi ..63.10 .3gi Aar 5q. 3D W 1
Si:a •‘1J ofCertified Well Contractor . Date
6.Is(are)the well(s): 1 'erman t or ❑Temporary By signing this form.1 hereby certify that the wells)wax(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing It ❑Yes or y(No copy of this record has been provided to theiwell owner.
If this is a repair,fill out known well co traction information and explain the name of the I.
repair under#21 remarks section or an the back ofthisfarm. 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 su ly wells ONLY with the same construction,you can
submit one form. r SUBMITTAL iNSTUCTIONS
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9.Totat well depth below lands :face: +O" (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lidge ent(example-3Qa 200'and 2Qa 100') construction to the following:
10.Static water level below top leasing: t40 (f.) DIvision of Water Quality,Information Processing Unit,
If[rater level is above casing,use,.,t" 1617 Mall Service Center;Raleigh,NC 27699-1617
11.Borehole diameter. PO241,.For Infection Wells: In addition to sending the farm to the address in 24a
Min
above,also submit a copy of this fo�within 30 days of completion of well
12.Well construction method: l 1 1 t l d. construction to the following:
(i.e.auger,rotary,cable,direct push, .)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WEL ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) 1 ' Method of test K,I01 24c.For Water Supply&Injection Wells: Ip addition to sending the form to
the addresses)above,also submit one 1 copy of this 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--I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013