GW1--01782_Well Construction - GW1_20240320

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Rex Meadows 14.WATERZONES --1
FROM TO DESCRIPTION
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) -
FROM TO DIAMET THICKNESS MATERIA
Clearwater Well Drilling Inc. ft. ft. t�) U t ; in.
Company Name 16.INNER C ING OR TUBING �L.
/(geothermal dosed-loop)
(�`� p FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: -loci 2 S 3 ft, it. 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
DAgricultural ft, ft. In.
g ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft, It. in.
❑Industrial/Commercial El Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation i ft. (9\I R, o()(Ilfl /)06 c ", !�
Non-Water Supply Well: `l X ��J(�I �(}
OMonitoring ❑Recovery ft. rt.
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) I
FROM TO MATERIAL 1 EMPLACEMENT METHOD
DAquifer Storage and Recovery ❑Salinity Barrier ft ft
DAquifer Test ❑Stormwater Drainage
—
ft. ft.
❑Expert mental Technology ❑Subsidence Control _
20.DRILLING LOG(attach additional sheets if necessary)
[JGeothermal(Closed Loop) ❑Tracer FROM O D SC IIPTION color,hardness,soiVrockt�pe,gralnsize,etc.)
❑Geothermal(Heating/Cooling Return) (� DOther(explain under#21 Remarks) \ ft () it. ALA k -
4.Date Well(s)Completed:(9 19 o24" Well ID# C R ON it. (�111 fl
Well Location:
: 1 fit- c ft. ( C LA U
Aft. S R.
E' er :�e_ .BnS vvt 2 To(Jui
fy
Facility/0 ner Name Facility iDDd(if applicable)
1100 S— �n(, Z?_ I )_ P-A, e JV4Ili f. ft. MAR ,� 0 2"Z4
P ysical Address,City,and Zip / w
1 c��� I �J 2LREMARKS ,��7r- -a Ur..,
i vz naG
County Parcel identification No.(PM)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: /22 er ication:
(if well field,one Int/long is s''ufficcient) G ,
71 .
Si ure of Cedi Led Well Cont actor Date
6.Is(are)the weli(s):XPermanent or ❑Temporary By signing this form, I hereby certify that the wells)was(were)constructed in accordance
with 1 5A NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes ortNo cope of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and esplairr the natnae of the
repair under#2I 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 atach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construdion,you can
submit one form C_ SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: < `-I'`J ((t.) 24a. For All Wells: Submit this tone within 30 days of completion of well
For multiple wells list all depths if different(example- , 00 v
3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: (... (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,me"+" 1617 Mail Service Center,Raleigh,INC 27699-1617
CD (
11.Borehole diameter: I S. (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
y� / above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 1 V��/�1Cr1 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: F�""1 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
completion of well construction to the county health department of the county
13b.Disinfection type: Amount: where constructed.
Fool GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

•
w.0 Misr SelfAiwa cartiticsdof
owner (Y J11ns NewWell:
-'71 7 83
I heriby oertify that the aixwe referenced weR was grouted iniappearance in accord wit%
all Cou tywd1mie
wdl Driller
� Pea clvi/01 s -%—
c,ertmearec: c9113-
Coanstru : Grout
Total ; TYl
Casing Type pie faithless: Xi d _
Cam: eo : a _
nl : Lo`i
Drive shoe:
GPM: I ,.