GW1--01778_Well Construction - GW1_20240320

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
I.Well Contractor Information:
Rex Meadows 14.WATER ZONES - H
FROM TO DESCRIPTION I
Well Contractor Name ft. ft.
2113-A ft, ft. -
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
n FROM Ia I DIAMETER THICKNESS MAATERIAL Clearwater Well Drilling Inc.
R. 1. s a. fl in. 3-fRI
Company Name (� 16.INNER CASING OR TUBING(&eothermal dosed-loop)
2.Well Construction Permit#: GCI�//�G FROM TO DiAMETER THICKNESS MATERIAL
r 11. TO
in.
List all upp/icahle well construction permits(i.e.County.State,Variance,etc.) _
iL ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipalPublic ft, ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. It. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) FTi18.OGROUTM TO MATERIAL .EMPLACEMENT METHOD&AMOUNT
❑Irrigation ,.>l i l ft. _Tm ft. /119. I
Non-Water Supply Well: v 1 Id(�
❑Monitoring ❑Recovery it, H.
Injection Well: ft. ft.
-
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO btATER1.ML EMPLACEMENT METHOD
ft. ft.
°Aquifer Test ❑Stormwater Drainage
❑Ex erimental9'echnolo II. ft'
p gy ❑Subsidence Control
❑Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIFTIO jcolar.hardness,solUrack type,grata size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) i ft• �l5 ft. ,` �� � ck r
Q (�
4.Date Well(s)Completed:l v i Well ID# ft. 51 jJ ft. '
f /5a.Wellall Location:c�i �/y Y1/ 1lnt1vmV I /�/11, S/ � ( ft. ]�t6j ft. �/�4��`J ' j d
J�I c' Ic1 c., ( T t�l vl c 61 l(! It M�( �ft. tan
ft.
L l I 1 ( I L.0 � .:
�- 't
FacilityiOwner Name J i CATAility ID#(if applicable)
e, LI ri_. L�1 Z- R. ft. .,^p k 2 0 2024
Physical Address,City,and Zip _
M?1C p' ' 21.REMARKS L
1.l"1 Iflii i>rfi:Di'_ .G. +.':.• UR l
County Parcel Identification No.(PIN) 1'
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: /
(if well field,one lavlong ii7s�slufficient) •
4 j 2 .Ce fkafion: 0
Si tore of Certified Well Contractor Date
6.is(are)the well(s):'ermanent or OTemporary
By sig nng this forme, I hereby cern&that the rents)uns turret constructed in accordance
with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards mid that a
7.Is this a repair to an existingwell: ❑Yes Yo or copy gjrlris record has been provided to the well owner.
If is a repair,fill out known well cornsnvction information mad T�rplaln the native of the
repair under#21 remarks section or on the hack of this jinni. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
B.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-crater supply wells ONLY with the same construction,you call
submit one Prin. C SUBMITTAL INSTUCTiONS
f�
9.Total well depth below land surface: 62 L�`J (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple urns list all depths ifdr/Jerent(erample-3(a,200'and 7(4,1001 construction to the following:
10.Static water level below top of casing: LP U (iL) Division of Water Quality,Information Processing Unit,
Illtater level is above casing,use
f"-+'I Q 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: �S/ ( [� (in.) 24b. For Injection Weill: In addition to sending the form to the address in 24a
12.Well construction method: I
-c (J- i above, also submit a copy of this form within 30 days of completion of well
(I 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
13a.Yield(gpm) (C Method of test: 24c.For Water Supply&Injection Wells: 1p addition to sending the form to
the address(es) above, also submit one copy df this form within 30 days of
13b.Disinfection type; Amount: completion of well construction to the county,health department of the county
where constructed.
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality uality
Revised Jan.2013

Well Driller Seli-erolut Cortilkailen
Q...cter v
Owner
'
Penrdt
I ,y certifytilS,that the above referenced well vats grouted in appearance in a000aaac►ae with
all County Welts.
9-
Weil Driller~ AMA OlAD , Signed:
D
Consort: Court:
Total Depth: 0 D� Type: C QMPCasing ripe:
-\ Thickness: �.l
casingDepth: LOB f:__
Diameter i0S
d
Drive Sloe: _
GPM: (Q -