GW1--02275_Well Construction - GW1_20240409

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WELL CONSTRUCTION RECORD
This form can be used for single or multi le wells For Internal Use ONLY:
1,Well Contrutor Worm II _
Rex Meadows 14.WATER ZONES
FROM ' To DESCRIPTION
Well Contractor Name g. R
2113-A ft. ft.
NC Well Contractor Certification Number 1:4 OUTER CASING(for mnitfeased wells)OR LINER(If applicable) —
FROM TO DIAMETER . THICKNESS MATERIAL
Clearwater Well Drilling Inc. C ff. I 45 fL Lea in. I pvc
Company Name Ifs INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 9i3LIR FROM DIAMETER THICKNESS MATERIAL�� ��� ft. ft. in
List all applicable well construction permits(i.e.County,State.Variance.etc.)
ft. ft In, I
3.Well Use(check well use): 17.8CREEN
Wolor Supply Wort: .e om 'ro vrnmarrna or,a7 alias TIIICIOiPbS DIATEKIAL
❑Agricultural OMunicipal/Public ft. fa In.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) IlLGROUT I .
FROM TO MATERIAL ' EM�PLACEMENTT METHOD&AMOUNT_
❑Iigation I ft. OD ft. 0�t malt L}1 1' 1 i1,i/,CC
Non-Water
Supply Well: ft.
❑Monitoring ❑Recovery
Injection Well: • H. ft.
°Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(If applicable) I
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL !EMPLACEMENT METHOD
ft. ft. I
❑Aquifer Test ' OStormwaterDrainage ft. ft.
❑Experimental Technology OSubsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,son/rock type,grain size,ere.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2I Remarks) ( f. CI-5— n. 8a rr i c(! 4- 1(Y -
4.Date Well(s)Completed: 2.2 I -2 Weu ID# C ir. 112- ft ,t�Ur�11 i�i I l—ill IL fL —I%3 �- ° UAGt I
5a.Well Locati /on: '
Dar\Ci i�et V-e.I -1 l ft. `iL(-S ft- ( 1(�.P/1.b}-C I
ft ft. :r'
Facility/Owner Name Facility 1D#(if applicable) ft. [ I it-.
ft. a -`' ' '`
% I�,.,.'L.:i, at/ 9.e
Otig A-r erg Cove, ild. ft. ft. h!' c 5 ?nail
L n v P ical Address,City,and Zip (b RG.r a'Svl I LI 21.REMARKS 1
U►�.rL�VC}1 betr'a`+--;T' 1�.;1 Prr^a.,t`.•sxn I wa 4
County Parcel Identification No.(PiN) )'4i`vCs`?S0G `"
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22. cation: 1
(if well field,one latllong is sufficient)
��, � a� N � ' c.Q' 4s3 W 3-a -a'l
Sig tire o-Certified Well Contractor Date
6.Is(are)the well(s):klrermanent or ClTemporary By signing this form.I hereby certi that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or No copy of this record has been provided to the well owner.
If this is a repalr,jlll out known well construction information and explain the nature of the
repair tinder 1121 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
S.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 I
submit one form. �— SUBMITTAL iNSTUCTIONS
9.Total well depth below land surface: —7 Lit,7 (go) 24a. For All Wells: Submit this form within 30 i days of completion of well
tf d For multiple wells list all depths ifferent(example-3Q200'and 2®100') 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,use"+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
V;It
11:Borehole diameter: i (in.) 24b.For Infection Wells: In addition to sending he 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: ro t CLN 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) 1 Method of test: /t�1� �] 24c.For Water Supply&Infection 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 nn,,nt,r

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