GW1--00514_Well Construction - GW1_20240118

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells -
1.Well Contractor Information:
14.WATER ZONES I
Rex Meadows _FROM TO DESCRIPTION '
Well Contractor Name ft. ft.
2113-A ft. ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LIN 311.(if applicable)
FROM TO DIAMETER i THICKNESS MATERIAL
Clearwater Well Drilling Inc. / R /0 ft. (a72 i"• I PV(1-
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
P y FROM TO DIAMETER r THICKNESS MATERIAL
2.Well Construction Permit/F: - II. ft. in-
List all applicable well construction permits(i.e.County.State.Variance,etc) ft. - R. in
3.Well Use(check well use): 17.SCREEN i
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Water Supply Well: ft. ft. in. ,
°Agricultural oMtmicipal/Public - -_
❑Geothermal(Heating/Cooling Supply) Xlesidential Water Supply(single) ft, I ft.
In. •
°Industrial/Commercial °Residential Water Supply(shared) 18.GROUT
FR/OM TO _ �l MATERIAL:.. `.FFMILACF.MENTMMEETHOD&AMOUNT
❑hri anon ft. 190 ft‘ to Ed- 1'4'
Non Water Supply Well: R, It.
❑Monitoring °Recovery •
[Mettler Welt: R. ft.
DAquiferRecharge DGronndwa.terRemediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL; EMPLACEMENT METHOD
°Aquifer Storage and Recovery OSalinity Barrier ft. R, ,
°AquiferTest °StormwaterDrainage P.
I°Experimental Technology °Subsidence Control i-- -- --1.-=-m--_. ----:-I-
20.DRILLING LOG(attach a lditten:0-ilmete if es aq'
I❑Geothetmal(Closed Loop) FROM TO DESCRIPTION(cola:,ba"risc:s,saiile4)pe,grata sire,etc.)
DTmcer°Geothermal(Heating/Cooling Return) °Other(explain under021 Remarks) fe• g.:7 R- �G k-,__` 1
'" ---- •-•,-.--==- t�•Cl:! L/ --2 . -`" ---_ --- �3SL /�/�ViL • ,i ,ramn •
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5a...te1!Location: 6/(i Q(J R�I `/��ft. 1 /tad[. f f ,
Facriiiciaw, Name resiiey II;ii(if epylleal,lej �- 1 j
((/D (Y HIV Ora(f S s Lc R •
_, .. R. s i..„ „„,.
Physical Address,City,and ip t)C 21.REMARKS JAN 1 n
a 2024
County Parcel Identification No,(PIN) lili:+i77:e:tr.il• r- n g 1_3102
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22. crtifica on: Gti`v:,, '• ,y
(if well field,one Iat/long is sufficient)
-5 'S7' /7'ia N g'd '40 (0,71K l� `f 073
w �_
Sig Certified Well Contractor I Date
6.Is(are)the well(s): Permanent or °Temporary By signing this form.I hereby certify that the nell(s)was(were)constructed in accordance
L ..
with ISA NCAC 02C.0100 or!SA NCAC 0IC.0200 ell StandardsConstrrctica and:,.c:..
7.1s this a repair to an existing well: °Yes or ilKo • copy of this record has been provided to the well owner
if this is a repair,fill out krona,well construction information and explain the nature of the !
repair under#21 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 dditional well site details or well
6.Number of wells constructed: construction details. You may also attach additi nal pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction.you can SUBMITTAL 1NSTL'C2'If)tiS i
submit one form. c//r-(16--- I
9.Total well depth below land surface: . (ft.), 24a. For AB Wells: Submit this 1 form withi 30 days of completion of well
For tntdtiple uvlic list all depths if dj rent(e.sanlple-302000'aan�d 2@100) construction to the following:
i� i
10.Static water level below top of casing: (ft.) Division of is'aier Qaaiuy,In fumy(lira PrUcL'53rtig[lydi,
Ifwater level is above casing use"+" (F. 1617 Mail Service Center,Ralei.h,NC 21699-16117
11.Borehole diameter: ill ( (in.) 24b.For injection Wens: in addition to send ng the form to the address in 24a
/r!Y/i �y�(q/// above,also submit a-copy of this fiirm withi 30 days of completion of well.
12.
ell�.,atrneti�a:^'.$:ad: ` v -__J.__ _ construction t0 the fgllnwiug
•. _*1 .�•::v. :�•2:;`:�li':.iy, '=c• :ter=3::i ar=y;tiive'v twill 1'rl brle3',
'�'i i 26 R�ait Service.^a rater,irctai•h +SC 9.7699- 436
svit'tinT%i�SUFFIX i tic-•w ONLY- a � - - _i.-�-• �� inn
3,9 I 24: For.- 5;tr:s::A'.1 �fii,.Wells: In addition.t'::J:e(v sending the :to
113a.Yield(gpnt) P.Iethod of test f •_ aa: _ _t_ -.• -_' _... . �r•t:_ r_.� ...cn: �n a .. r
• 1 completion of weii eeasrmctien so the count} health department of the county
I13h.Disinfection,yne: Amount:
I where constructed.
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