GW1--00754_Well Construction - GW1_20240131

WELL CONSTRUCTION RECORD I
This form can be used for single or multiple wells I For Internal Use ONLY: J
1.Well Contractor Information:
Rex Meadows 14.WATER ZONES
• FROM 1 TO DESCRIPTION
Well Contractor Name ft. ft.
2113-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for mul&cased wells)OR INNER(If appncable)
FROM I TOn DIAMETER ICKN� 1 MATERIALClearwater Well Drilling Inc.
Company Name % I NN t�� 1 ���
16.INNER CASING TUBING(geothermal closed-loop)
FROM TO DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. i in. I
List all applicable well construction permits(i.e.County.State.Variance,eta)
ft. ft. I in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER; SLOT SIZE THICKNESS MATERIAL
°Agricultural Municipal/Public ft. H. t°•!
❑Geothermal(Heating/Cooling Supply) IXResidential Water Supply(single) R. In.'
❑Industrial/Commercial °Residential Water Supply(shared) IL GROUT -
❑aigation FRO TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: / ft. ) O jY a .
°Monitoring ❑Recoveryft. ft.
Injection Well: • H. ft.
[Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVELPACK(If applicable) I
❑Aquifer Storage and Recovery Q$gljnjty RanierFROM TO MATERIAL I EMPLACEMENT METHOD
°A uifer Test ft. R.
q ❑StmDrwater Drainage
❑Experimental Technology °Subsidence Control ft.
OGeothennal(Closed Loop) ❑Tracer 2o.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(rotor.hardness,soWrock type.grain size.etc.)
❑Geothermal(Heating/Cooling11Return) ❑Other(explain under#21 Remarks) / ft. 57 ft. S /Y -/,/
4.Date Well(s)Compl ted:l9l // 3We/D-IDtIY1��� {5 7 ft• (OKA ft k e I�c/c�t
5a.Well Location: >�I i J LX�h cciS t ►U! /tt Iatc GY"A H• of•�R• i r e I
c��U��f n �z J�h 1p83it" 70Sft- ,lqr)2/1W..f .;-:� - r�•--•
s.
l H. fr. t, `»_ ,.4.,,.t'LL -t; �v La Facility/Owner Named
�, n/� �^��%(sd r )Facility
s] (if applicable)
l � !�On., /!! - r 1 Ll t� ft [t. fIAN •
Physical Address,City, Zip ft. fL 3 ? 2 24
/C 21.REMARKc to .:;"ilht:ir/'fn rir-(7-1's?C:?*?a UicY
f f �-� I DWQi2OG
Count/ Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: l
(if well field,one let/longis sufficient) 27t.Cer"r on:
3'5�- tZZO N ' I '3Fa W / -27 073
, � Si ertified Well Contractor Date
6.Is(are)the well(s):ji( ermanent or QTemporary
\ By signing this form.I hereby cert •that the tariffs)Is(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Will!Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or J�No copy oj'this record has been provided to the wellow ner.
If this is a repair,fill out known well construction information annd�aptain the nature of the 1
repair under#21 remarks section anon the back of thisfemr. 23.Site diagram or additional well details:
You may use the back of this page to provide a ditional well site details or well
8.Number of wells constructed: construction details. You may also attach additio r I pages if necessary.
For multiple injection or non-water supply wells ONLYwith the same consirttetion.you can I
submit one form. /�} SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: �(�� (fL) 24a. For All Wells: Submit this form within 0 days of completion of well
Far multiple mils list all depths(I-different(esample-310200'and 2C100) construction to the following:
10.Static water level below top of casing: (OO (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing use"+" i 1617 Mail Service Center;Raleigh,NC 27699-1617
11.Borehole diameter: /F (in) . 24b.For Infection Wells: In addition to sending the form to the address in 24a
y o�I above,also submit a copy of this form]within 0 days of completion of well
12.Well construction method: ' V' construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY LLS ONLY: 1636 Mail Service Center,IRaleig NC 27699-1636
13a.Yield(pm) Method of test: /9 24c.For Water Supply&Infection Wells: In a ition to sending the form to
the address(es)above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county h Ith department of the county
where constructed.
Form G W-I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013

Will Mier S•11.41rout owdfigavden,
atii2iu'iCas gal/a&
Ow= owcwi . ,6A__ J New Well:
A drk exiq.12 Pnil# tr. RepairL..
Permit
•
1111343y Cfsdfy tbat the above reamed wall was muted in appearance in monk=with
all CounLyWeUiies.
Well Dam Aleockwf sow:
Certfficate#: 021/3-A- Datbelionud: 7-,V
canstection: Quo
Tot Deth: -7 04.5—
TYPe:
Casing ype: pv Thidmess: Li,"ci
Casing Deg): g7 Del/111_4Q P
Dameter; (ail(F.- •
Helot:
Drive Shoe:
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