GW1--06257_Well Construction - GW1_20230925

WELL CONSTRUCTION RECORD
For internal Use ONLY:
This form can be used for single or multiple wells Ill
1.Well Contractor Information: -
Rex Meadows 14.WATER ZONES
FROM TO DESCRIPTION
Well ContractorName ft. ft
2113-A it. «. ;
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if ap llcable)
FROM TO DIAMETER THICKNESS 1 MATERIAL
Clearwater Well Drilling Inc. I «. It) It WI 1n. I DUC,
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
MCC
�I ^ FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: I(��`�I CX�/ ft. ft , is
List all applicable hell construction permits(i.e.County,State.Variance,etc.)
ft. ft in.
3.Well Use(check well use): 17.SCREEN
"
Water Supply Well: • FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
[Agricultural OMunicipal/Public It ft in, I
°Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R. ft. In I
❑Indust ial/Commercial °Residential Water Supply(shared) 1&GROUTI
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[Irrigation ` tt' r�o ft. C.e x 1 t 1 1 i{(Lid
Non-Water Supply Well:
ft. ft.
[Monitoring [Recovery
Injection Well: • ft. ft.
°Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) I
[Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
ft. ft. I
❑Aquifer Test OStomnvater Drainage
ft. a. I
❑Experimental Technology ['Subsidence Control 20,DRILLING LOG(attach additional sheets if necessary)
°Geothermal(Closed Loop) °Tracer FROM TO DESCRIPTION(color,hardness,solurock type,grata size,etc.)
°Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) '1 it• IC) ft. P�-4 Jl�' r 1 [ I Y+
1.p It 24\ it, giant le
4.Date Weil(s)Completed: Well[D# 241
I tt. -7�7ft. CI
!1
Sa Well Location: "i L� lX
Kec\� -) 1\ 2y 7 eft. ft. 911.-4-\‘ � I
ft H. i
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
r t l lG rl 4 4 ft. tG iaiJ'L,..z I i MP Ito'
Physical Adds s,Cit ��y and Zip f a -c)S\j tire-'
QC' 21.REMARKS l
ce r 0�1.�.t 1 i t S E r I4 5 `023
Codnty Parcel Identification No.(PIN) I
1 f �c�l(�yr;�. Ui;3
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22. er•tcahoD. f�t�"�:i°f'•it`[DtnC-1:
(if well field,one lat/tong is sufficient)
a5rQ� t�tqra�N far aol ' i4-.5s W .,1-- --- 1 1 1- 1 -23
Si ore of died Well Contractor Date
6.Is(are)the well(s): O ermanent or °Temporary By signing this form.I hereby certify that the wells was(were)constructed in accordance
with ISA NCAC D2C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: °Yes orlo copy of this record has been provided to the well own .
If this is a repair,fill out known well construction information and explain the nature of the '
repair under lull 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 provideadditional well site details or well
8.Number of wells constructed: construction details. You may also attach addi ional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can I
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: a©5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdrfferent(example-3@200'and 26'100') construction to the following:
10.Static water level below top of casing: (-0 0 (ft.) Division of Water Quality,information Processing Unit,
If water level is above casing,use"+'t` 1617 Mail Service Center`,Ral igh,NC 27694 1 617
11.Borehole diameter: LC) t (in.) 24b.For Infection Wells: In addition to sew 'ng the form to the address in 24a
1 above,also submit a copy of this farm wi 'n 30 days of completion of well
12.Well construction method: roi-otruconstruction to the following: i
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Undergroun Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) Method of test: l� 24c.For Water Supply&Infection Wells: >s addition to sending the form to
the address(es) above, also submit one;cool 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-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

_
Well DrMer SeW-Grout Cordikadon
Owner: e,
"uole' I
Pernilh
ri *certify that the above referenced well was grouted in appearance inataXtUVith
all thinly Wit nes.
well Driller. Sped:
Date,Grouird:
Qmstrudkax (km t
Total Deo:ft...3_05_ TYPe: 1-
CaSingTYPeLPL-Ce---, Thickness:
Casing Deitql---- Depth:
Diameterz_Qi--
Height—
Drive Shoe:----_