GW1--01780_Well Construction - GW1_20240320

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information:
• Rex Meadows 14.WATER ZONES j
Well Contractor Name FROM TO DESCRIP'I1pN
fL ft.
2113-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells OR LINER(if, nllcabe)
Clearwater Well Drilling Inc. FROG' IL
J H DIAMETER THICKNESS MATERIAL
to
Company Name
-1 3 ( V
16.INNER CASING OR TUBING( eothertttal closed-look
2.Well Construction Permit#: FROM TO DIAMETER KN
List all applicable nell construction permits(i.e.Count}.State.Variance eie.lf'' ft. I1ThIcIf:T1
3.Well Use(check well use): ft•
Water Supply Well: l 17.SCREEN
FROM TO DIAMETER:s SLOT SIZE THICKNESS MATERIAL
Agticulturol , LL� �'I pMunicipal/Public
ft. ft. in
C IGeothennal(Heating/Cooling Supply) DResidential Water Supply(single) It. ft. In.
❑Industrial/Commercial 0 Residential Water Supply(shared) IS.GROUT
❑Itrigati0n FROM TO MATERIAL EMPLACEMENT METHOD 3 AMOUNT
Non-Water Supply Well: I ft' 00 ft-
OMonitoling ORecovery fl. ft.
Injection Well: ft. ft. ---
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVE!,PACK(if applicable)
DAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL
EMPLACEMENT
DAquifer Test ❑S ft. ft. -
tormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. ft.
DGeothemral(Closed Loop) OTracer 20.DRILLING LOG(attach additional sbccts if necessary)
FROM TO DESCRIPTION(color,hardier-as,soli/rock nor,grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I rt. 3`;rt. Si,r iAl /
4.Date Well(s)Completed:()-.3 Well ID# ( J It. J f'. r�� _.l\ -f-
Sa.Well Location: Oft. _2,.,n 2 r ( i
l u li:1 i t l re C 1 e.. 1 ft. � ft. JL.�t tL"
Facility:OwnerName J ft. it.
Facility IDI�V O'fopplicable) t,..-,e i�,.; ..i e-
(4�q fi\) , MLI P ) Yfxs A 1.1 ft. MAR 2 0 2024
Physical Address,City,and Zip j
M1+OXV ( 21.REMARKS .
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) C 22.Ce fieation:
lU I ° 041 N J c)N Lip W 4..-____, . '.-' , 0 -N3' - q
ignature of Certified Well Contractor Date
6.Is(are)the well(s):APermanent or DTemporary '
f \ By signing this jonm. 1 hereby ceriift that the uell(s)was(were)constructed in accordance
with/5.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or o
If this is a repair,fill out Anotnt well construction information and explain the nature oldie copy of this record has been provided to the neli owner.
repair under tt21 remarks section or on the hack 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 a
For multiple injection or non-ureter supply wells ONLY with the same construction,you cart p ges if necessary.
submit one/urm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: L{'( 1,J (tL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple Hells list all dept/cv if different(example-.11k200'anrl2(a 100) construction to the following:
10.Static water level below top of casing: LS/l .' Division of WaterProcessing Unit,
If nutty level is above truing,use"+" (ft.) Quality,Information� //��`I n 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: l y U (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
-/�i( l above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: f.,( 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) J Method of test: P_-e(I1 24c.For Water Supply&Injection Wells: In addition 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 health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality
Revised Jan.2013

Wail pIMr SalaLayout CMl111cadon
Owner: X nfik-r4 l 0-e.ety, New Well:
5, ..0lc Repair:
Pet
I hereby certify tit the above referenced well wait grouted in appearance In accordance with
all County Well mies.
well Driller R Kead OuC25 Signed:
card #: 113 - A- Date Grouted: 1. ..:-
Constr ctk E (knit:
Total Depth: LA-CS- Type:
Thidmess: m\ c
Depth:Casing - :__ �..
Diameter:.
Weight/Mick
Ht
Drive Shoe:
GPM