GW1--00706_Well Construction - GW1_20240125

I
WELL CONSTRUCTION RECORD f "
For Intennl Use ONLY: i
This forth can be used for single or multiple wells i
1.Well Contractor information:
Rex Meadows 14.WATERZONES I { I
FROM TO DESCRIPTION I Well Contractor Name R. R. I I I _
2113-A ft. ft. I I I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap Ucable) .
FROM TO DIAMETER ' THICKNESS MATERIAL
Clearwater Well Drilling Inc. ` IL 40 rt. "'SI- ht. pvi.
Company Name ��!! / 16..INNER CASING OR G(geothermal closjed-loop)
X� �` FROM TO DIAMETER . THICKNESS MATERIAL
2.Well Construction Permit/1: U J ft. ft. 1 in.
List all applicable well construction permits(.e.County,State,Variance,etc.)
H. ft i,in.
3.Well Use(check well use): 17.SCREEN )
Water Supply Well: FROM TO DIAMETER SLOTSIZEI THICKNESS MATERIAL
ft. ft. in.
❑Agricultural lMunicipal/Public
❑Geothermal(Heating/Cooling Supply) �IResidential Water Supply(single) ft. in-
❑IndustriaUCornmereial ❑Residential Water Supply(shared) 18.GROUT - I
FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation t it. ft. /'�e-n1_ r
Non-Water Supply Well: ft. it ( T
❑Monitoring ❑Recovery
Injection Well: R. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(If applicable) i
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier R. ft. _
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPyTI�ONN ccolor,bakdness,satUmck
OGeothermal / if. (JV 2 (2'lf, l/ f rL �'aR1°msr�,elc.)
(Heating/Cooling Return)/ ❑Other(explain under#21 Remarks) �} �l t yvi
4.Date Well(s)Completed: /t?/`7?4ell ID# CIO ti' 697 7 ti• `r/ itt _4-
/7.7 ft Gonna- , `l
5a Well Location: // �l _ rs�`
on" 7oS ft 9 ?Io1- 'I
Y *•' -..
: � '
Facility/Owner Name Facility ID#(if applicable) ft. ft. ,�„ '"r ,. A f
4---51 Nt1fnphccL 1411) . td �RCQ. ft. ft.
Physical Address,City,an Zip 11) '�o I J A N 2 5 1014
I
M.1 --�h T-I M �V`^� 21.REMARKSlntfr'`rrl Pri.':.7J.1.S f j UFA
County Parcel Identification No.(PiN) I il-iie "= :JC.;
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2 -Certi anon:
(if well field,one lat/long is sufficient) t /
e tcs" • q Ng.. 0 s701 W .----z — la 7 c23
ture....2S.Cenified Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing This form I hereby certify that the xetl(s)ryas(were)constructed in accordance
)(Permanent
` with ISA NCAC 02C.0100 or ISA NCAC OZC.0200 W II Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or io copy of this record has been provided to the well owner.
If this is a repair,fill out dironn well construction Information an�rd lain the nature of the
repair under 021 remarks section or on the back of this four 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.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit anefonn. (('�� SUBMITTAL INSTUCTIONS
--(V
9.Total well depth below land surface: I � (ft.) 24a. For All Wells: Submit this form withi 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@l00') construction to the following:
10.Static water level below top of casing: 10 (ft.) Division of Water Quality;Informs'on Processing Unit,
If water level is above casing,use-+" 1 1617 Mall Service Center,Ralei ,NC 27699-1617
11.Borehole diameter: 1.0 I (in) 24b.For Injection Wells: In addition to sendi g the form to the address in 24a
12.Well construction method: (,�
�r)+n N above, also submit a copy of this form,'withi 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground njection Control Program,
FOR WATER SUPPLY
WELLS ONLY: 1636 Mail Service Center,lRalei NC 27699-1636
13a.Yield(gpm)_ Uf Method of test 24c.For Water Supply&IDiection Wells: inddition to sending the form to
the address(es) above,also submit orie'copy elf this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county lealth department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality I Revised Jan.2013

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oviater:_ke,d QhnDD
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Adthes1631-aL146-0-diaa
Paisit_IT1-J-(21S---- '
Limbs,-ceiiifythat lite above referenced well we:grained in appearan1ñ=eta=with
all CountyWdi rules.
wen Dia= Rek V\-(0 CA.GtZ-C- g . r , ,
Certlfleatelt: c; 1‘3 -4 DoloGloulEdLiaja,;,,d3.--
Crmstructkat CAVIIIt 1
1
Totid Depth; 1 DT Cerra-NJ- '
Casing Type: pvc_ Thickness; fn(Nt i (1
Oising Depth: 40 Depth: ao
Diameter:
Hz . 1
Ware
GPM: cD