GW1--00523_Well Construction - GW1_20240118

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I I
1.Well Contractor Information:
Rex Meadows 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2113-A ft. ft. 1
NC Well Contractor Certification Number 15.OUTER CASING(tor multi-cased wells)OR Lit RQrapplicable)
FROM ' TO DWAMETEttt I flu MATERIAL
Clearwater Well Drilling inc. J ft. ft. tej% .,.. In; pvc
Company Name 16,INNER CASING OR TUBING(geothermal dosed loop)
F72011. TO DIAMETER- THICK 41ATERiAL
?.Wt'l!t'3i sti r},bust?rrt tttit i: !t. R. in: }
• List all applicable well construction permits(i.e.County,State,Variance,etc.) R. I R. I ;in,
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3.Well Use(check well use): 17.SCREEN 1 _ i
Water Supply Etieii: -_ -_ 1{ item-v --4;- _- ' iii.;i4'v^et i;1.ei::.fF. .--_: ; ' `:: ti:r:ar_? .
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OAgricultural DMunicipal/Fublie1
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i DAquifer Recharge OGroundwater Remediation Sr114(}IG1tAVEd,1�,�Ci:tifahtlIeeble) -_Y� cti
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Physical Address,City,and Zip 21.REMARKS _1 A, VI I LU
-24
/4 Qdi5nli I - :7 i,�N. 1
County Parcel Identification No.(PIN) ;trit, 1T.71 t� `".''
!11' n.Vj 2r�i.
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22: flea' it: _-
(if well field,one tat/long is sufficient)
35' S� r�' 7 N ?) '- / 101'7 W / - /)-4-a3
sib: fCertified Well Contractor I Date
6.is(are)the well(s): ermanent or CITemporaly By signing this form.i hereby cent l'that the welll(s)was(were)constructed in accordance
with iI I NCAC 02C.0100 or 15A NCAC 02C.0200 Wel Construction Standards and that a
7.Is this a repair:to no existing well: Dices or 1 41.(1 copy of this record has been provided to the w ill owner.
If this is a repair.fell out bunco well construction im;urmnatioa and captain the nature oldie
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 ad r itional well site details or well
8.Number of wells constructed: construction details. You may also attach addition 1 pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
1 SUBMITTAI.u!STUCT1ONS
sal:mit-ore form. i j� I'
9.Tetal well depth below land surface: 7 (ft.) xsta- For All Weiss: Submit this form within .0 days of completion of well
Par multiple wells hat sill depths if dWèrcnt(panne-3!J20n'and 2@1Qn') construction to the,following. 1
10.Static wafer loves below tog of casing: 70 (so iltvisiotr c-i ki:'a cr Quittit,Etrlorutats a t'ruc:•:w:og t_ens
limiter lerel is abase casing,use"+" j 1617 Mail Service Center,Ralegt' NC 27699-1617
II.Ku.,Itiil diameter: [/,0 /6(, (in.) 2db-Fur loins-ton Weft In addition to serdirt the form to the addra s in 24a
�� above. also submit a cony of this form within 30 days of completion of well
12 :lei':an:fiction Itretim± ;;st t tiro to he rtt uriug:
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i 13a.Yield(gnta -,_!?. `Method of test: &' i __u e:`=:a:: ��:: V' �: - -c. � :::ry c:c -Vr.
l�l/fjil JO WA CO I conlmlcuon of well construction to she eounty tl hit department of the county
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thereby nerdtriltat the rtaverefesestoed we sues wonted in appertrancnb vdth
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