GW1--01781_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
FROM TO DESCRIPTION i
Well Contractor Name ft. ft. I
2113-A ft- ft. -
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased weits.)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. It ft. 7,(.„.0 ft. 1jvVr,- In. 'I,
1
Company Name 16.INNER CASING OR TUBING(geoth errnal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit tt: ft. ft. in.
List all applicable well construction permits(i.e.County,State, Variance,etc.) _
ft. ft. in. —
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER ;SLOT SIZE THICKNESS MATERIAL
' gricultural - (`l-k—rf�`1 ^t `' ❑Municipal/Wblic ft. ft. in.�
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
ft. ft. In.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation t �� n
Non-Water Supply Well: i rt. 9 J rt. Oe l i t r ' 1 ,( 1J
❑Monitoring ❑Recov ft. ft. " i 1�( a
Recovery
Injection Well: ft. ft.
i
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) 1
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
R. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO i DESCRIPTION icotnr,hardness,soll/rook type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) i ft• J( ) it. `�f i)//` ;-j /: 1--
4.Date Well(s)Completed: '1`--1--0C1Well ID# j() R' rt. , k Y J+11i
5a.Well Location: i 11 ft C rt.
t rA•i�rh 11l
ft. H. ;
Facility/Owner Name Facility iD/(if applicable) , "-
It. ft. �,.,,• Le..
:-.-2) ('1 0- ec)- P-Xa lYh i l(a1Mil l ti, ft. it. —VAR 2 0 CuZ4
Physical Address,City,and Zip 21.REMARKS _
`t ,AT 0 1`�,�1 SC w a(:�>
County Parcel Identification No.(PIN) ,rVl�l..r�%��.�
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: .,2 Ce fixation: i
(if well field,one Ial/long is sufficient)
t ,
A o ( 34.3 N `s [54 .qq W %.i ' 1(0 � `{
Sigruture of Certified Well Contract° Date
6.Is(are)the well(s): permanent or ❑Temporary By signing this fauna. 1 hereby ccrti� That the nett(.)was(acre)constructed in accordance
stilt!SA NCAC oo2C.0100 or I SA NCAC 02C.0200{fell 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 known well construction information and explain the nature of the
repair under 42l 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.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: c S (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple Ire/s list all depths ifdiljerent(example-3@ 200'and 2ia•100') construction to the following:
10.Static water level below top of casing: LCO (ft.) Division of Water Quality,Information Processing Unit,
if toter level is above casing.use-A-- \ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ( (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: I"C)+ofuj 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) v Method of test: i � -1 24c.For Water Supply&Injection Wells: In addition to sending the form to
tfte 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-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

yr, r SelliAtiout Cordtkation
Owner: ; hson New Welk Vra-rrf. U)Af
Repair, .
I hen thy certify that the above referenced well vine glowed in appearance in=cedar=with
all County Weil miss.
weft Dxiner_ )-P e pc(�S Sited: r
Certificate#: 1 ti - Date Gat: . }�
Cnnstr cd n: Gm*.
Total Dept: c9r) - czxne
.
Casing T > Thirkr s^_ f 4 I C.1
Depth:Casing : (30..
Diameter:
Drive Shoe:
GPM: G h