GW1--00705_Well Construction - GW1_20240125

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: , ,
Rex Meadows lr4aWATER ZONE8 DESCRIPT TO ION
Well Contractor Name R' ft. I
2113-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap lieable)
FROM TO DIAMETER , THICKNESS MATERIAL
Clearwater Welt Drilling Inc. 1 IL 3 IL U21` I`in. e,
Company Name 16.INNERCAS G ORTUBING(geothermal el -loop)
FROM TO DIAMETER ' THICKNESS MATERIAL
2.Well Construction Permit if: ft. ft. in.
List all applicable well construction permits(i.e.County,State.Variance.etc.) B, ft.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSiZEI THICKNESS MATERIAL
❑Agricultural OMunicipal/Public D. D. is I
OGeothemial(Heating/Cooling Supply) l Rtsidential Water Supply(single) R. R. in
❑Industrial/Commercial °Residential Water Supply(shared) i8.GROUT I
FROM TO MATERIAL p. EMPLACEMENTMETHOD&AMOUNT
°irrigation, 1 IL D ft- came rnQ;Q ,-1 111 t(ui(.t
Non-Water Supply Well:
ft. H.
❑Monitoring °Recovery
injection Well: ft. IL !
°Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK Of applicable) • 1
PROM
❑Aquifer Storage and Recovery ❑Salinity Barrier U.
TO f. MATERIALEMPLACEMEhTbtETHOD
°Aquifer Test OStonnwaterDrainage R ft.
❑Experimental Technology ❑Subsidence Control 1
20.DRILLING LOG(attach additional sheets If ncfessary)
°Geothermal(Closed Loop) °Tracer FROM TO DESCRIPTION(calor,hirdness,3onlroek type.grain she.etc.)
°Geothermal(Heating/Cooling Returrnn)/� °Other(explain under#21 Remarks) R' 434 rt. (��r no d 4- i-
1 u
4.Date Well(s)Completed: It ? Well ID#i 3 at EL `J�1
1 3Le)-R �r,i
(ci c-fi t Lt.
Sa Well Location: ft. it 0)\-(1."4-6 ,--- — --,----
Facility/Owner Name Facility ID#(if applicable) R i I ��{ �w� %, �
R. ft. . JAN ° 5 v)fr)fi
Physicalyyyy Address,City,and Zip v-t p/l ei P nF, KC 21.REMARKS !, 1 ,.-.i+i_7:7'.•',ir��. P r—r F_',,i;'�`t lea'
Pt1�t ,her l I i t/�1,. r 1 "r i I, Lf a s O
County Parcel Identification No.(PiN) /
5b.Latitude and Longitude in degrees/ntinuteslseconds or decimal degrees: (22.C tilication:
(if well field,one laUlong is sufficient)
3'53 ' CAST N Y t D' '5 ? W :__._/ - 11—/1-Z3
S lied Well Con Date
6.Is(are)the well(s): (Permanent or °Temporary By signing this Jam I hereby certi r s) us(Were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC,02C.0200 ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or o copy of this record has been provided to the well oane
lfthis isa repair,fill out knatsn well construction Information a lain the nature ofthe I'
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 additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
Aar multiple injection or non-water supply mills ONLY with the same construction,you can !
submit one form SUBMITTALINSTUCTIONS '
9.Total well depth below land surface: (ft;) 24a. For All Wells: Submit this'form withi 30 days of completion of well
For multiple wells list all depths if afferent(example-3@200'aad 2©W) construction to the following:
10.Static water level below top of casing: COO (ft.) Division of Water Quality;Inform lion Processing Unit,
If water level is above casing.use"+"i 1617 Mail Service Center,Ralei h,NC 27699-1617
11.Borehole diameter: (.0 [ (in.) 24b.For Injection Wells: In addition to sen g the form to the address in 24a
�,r, t n,m 0 above, also submit a copy of this'form with' 30 days of completion of well
12.Well construction method: U-�(�I construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Undergroun Injection Control Program,
FOR WATER SUPPLY'WELLS ONLY: (Lvf
1636 Mail Service Center,Raleigh,NC 27699-1636
13a Yield(gpm) ` ) Method Direst: 24c.For Water Slimly&'illation Wells: in addition to sending the form to
the address(es)above,also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
13b.Disinfection type: Amount: where constructed.
Form GW-i North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013

Will DOW SeMANnit CiNgegaVon
Thereby ontlfyThat the abovereferenaed well was grouted in appeannicellFt Occoldince with
all CamtyWell mks.
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