GW1--00596_Well Construction - GW1_20240118

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple welds
1.Well Contractor Information:
14.WATERZONES I
Rex Meadows FROM TO DESCRIPTION
IWell Contractor Name ft. R-
2113-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licab1e)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. R � fL gyp/r 'in• I pve,
Company Name 1 .INNER CASING OR TUBING(geothermal dosed-loop)
0Q? aD �S FROM TO DIAMETER THICKNESS MATERIAL2.Well Construction Permit it: ft. B, in.
all applicable well construction permits(i.e.County.State.Variance.etc.) R. ft. 'in.
3.Well Use(check well use): 17.SCREEN I
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural 0 Municipal/Public
❑Geothermal(Heating/Cooling Supply) jgResidential Water Supply(single)
ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL
Q,.�/�EMPLACEMENT METHOD&AMOUNT
❑Irrigation / ft. d'0 ft. Cei22 ' ]I- ////f i
Non-Water Supply Well: ft. R.
oMonitoring L]Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) I
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fL R.
❑Aquifer Test ❑Stormwater Drainage ft. R.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color.
hardness.soollfinek hype,groin size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) R' 8. ' ft SZn ei4 1( 0
3 ft- 371 If. r
4.Date Well(s)Completed: i -ER-- Well I. 37/4 R. 3 7 L R• ,,/ // 0
.
5a,Well Location: 37,R 1i 51 Teal,/ l
6/ill b/00//eS. R.
ff.
Facility/Owner Name jCIlityiD#(ifapplicable) it. ft p/03 &tl 1V r (Yee 1..eirskr ft. ft a M.
e r$ v qg..,Li
Physical Address,City,and Zip 21.REMARKS I J'6 N 1 .0 L G L`t
tipeornhe,
County Parcel Identification No.(PIN) / inczi.l;cc4igll P;;.C.`.35? ;.g Up,,i
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cer fi on: Lyi v I'jJ�
(if well field,one lat/long is sufficient) �} •
tt 11c Ia77 N bo) 3Y :&341 W --7_ . _ 11-?-,2
S' nature of Certified Well Contractor Date
6.Is(are)the well(s): Wermanent or ❑Temporary By signing this form,I hereby cert fi'that the vvell(s,was(were)constructed in accordance
with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: [Wes or No copy of this record has been provided to'the well owner.
If this is a repair.fill out known well construction information an explain the nature of the 23.Site diagram or additional well details:
repair under 021 remarks section or on the back of this form.
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 supply wells ONLY with tiresome construction,you can SUBMITTAL INSTUCTIONS
submit ono farm. ���
9.Total well depth below land surface: (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3C200'and 2@l00') construction to the following: i
10.Static water level below top of casing: Cg v (ft.) Division of Water Quality,Infornation Processing Unit,
If water level is abore casing,use
"+"( 1617 Mail Service Center,Ral igh,NC 27699-1617
11.Borehole diameter: V° r F (in.) 24b.For Injection Wells: In addition to se ding the form to the address in 24a
above,also submit a copy of this form wit in 30 days of completion of well
12.Well construction method: r 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 Center,Raleigh,NC 27699-1636
�j(� Method of test 24c.For Water Supply&Injection Wells: ti addition to sending the form to
13a.Yield(gpm) vv , the addresses) above, also submit one copy of this form within 30 days of
completion of well construction'to the coun.y health department of the county
13b.Disinfection type: Amount: where constructed. I
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Watei-Quality Revised Ian.2013