GW1--02277_Well Construction - GW1_20240409

I
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 I
FROM TO DESCRIPTION
Well Contractor Name
I
ft. ft.
2113-A
ft. ft. i
NC Well Contractor Certification Number IS.OUTER CASING for multLcased weRs OR LINER if linable
Clearwater Weli Drilling Inc. FROM TO DIAMETER THICKNESS MATERIAL
J ft. ft:
Company Name 16.INNER CASING OR TUBING'eotitcrmol closed-ioo
2.Well Construction Permit 8: Z" t/7,- OD�-�l J EOM TO DIAMETER tCKNEss
[L MATERIAL
List all applicable well construction penults(i.e.Comm,.State.Variance,etc.) ft. ill'
3.Well Use(check well use): ft ft. io
Water Supply Well: l7.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgticuitural ❑MunicipaUAublic R. it. in.
CI Geothermal(Heating/Cooling Supply) Residential Water Supply(single) IL B. In. I
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑litigation FROM 'To - I
MATERAL IEMPLACEMENT METHOD&AMOUNT
Non•Water Supply Well: t ft' ao ft. !CYiQ '\tI
� Cp.❑Monitoring ❑Recovery n• R. �-/
Injection Well: ft. ft.
°Aquifer Recharge DGroundwater Rentediation 19.SAND/GRAVEL PACK(If appUeablee l
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test rt. ft.
❑Stormwater Drainage
°Experimental Technology ❑Subsidence Control ft. ft.
20.DRILLING LOG(attach additional sheets If necessary)
❑Geothermal(Closed Loop) OTracer
❑Gee;hemlal(Heating/CaDiing Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(priori tor-slater,mtilmek Rpa,wale size,eta)
nct
4.Date Well(s)Completed:g-I V'2- f « �4-f-it.
c � It
�( (t
Veil ID# , r URi 1 t
�a.Well Location: H' yQ SR• .C�`
�'7PY1 axYlin l .i�5oh at-it- K 5 ft. rt ,�,r it
Facility't7nerName ft. ft. I -
Facility KM(if applicable)
� • R.D OpnnI5 r--, cR4 ,;�aLf(,"`... '%
V P.7 a )5 p
� ONhe: 21.REMARKS I
??
County Parcel Identification No.(PIN) A�K eoL4
in degrees/minutes/seconds !�`� ^'^ , r.
Longitude or decimal degrees:
- ;;,;,.y
Sb.Latitude and
Oliva field,one lat/long is sufficient) 22.C rti allowsib
i
c' 4---at 5-614 N Ca ' 3W ( sn W 3 --20-2i
Si o Certified Well Contractor Date
6.Is(are)the well(s):tkermanent or ❑Temporary
By signing this form.I hereby certl)y that the nell(s)was(Here)constructed in accordance
Is a repair7.Is this a repair to an existing well: ❑Yes or a D with!SA NCAC 02C.0100 or!SA NCAC 02C.0200 Well Construction Standards and drat a
raids •jlll out known well corstructlon Information rplain the nature oftire copy of ibis record hat been provided to the well moat.
repair under#2!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 additi nal pages if necessary.
For multiple injection ar►ton-rtntersupply wells ONLY with the same construction,you can
snbmitonefurm' SUBMITTAL iNSTUCrroNs
9.Total well depth below land surface: 535- (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijlerent(example-3G00`and 203100•) construction to the following:
10.Static water level below top of casing: U Q (ft) Division of Water Quality,,lnfornultion Processing Unit,
Owlet Ic+rl is above casing use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: .l� 1
l an.) 24b.For Injection Wells: In addition Ito sending the form to the address in 24a
12.Well construction method: l 'A� above,also submit a copy of this form withit>!30 days of completion of well
�l 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,Ralei h,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:.in addition to sending the form to
the address(es) above, also submit one copy o this form within 30-days of
13b.Disinfection type: Amount: completion of well construction to the'county ealth department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality
Revised Jan.2013

(
Will Driller SeiMilroot Cardilication
Owner:32.61 , . ICIRriNiew Wet \7•
Adiress ,aa rq S Repair:
pennit 2022- Opc
riumby milt/That the shave referenced well was wonted in appearance in accordance with
all CountrWeil rules.
Welt DAM K Pk(ct_cout.7J
ceraffrate#: 2,9
Construction: Grout
Total Depth: /57s" TYPe:2 IkX
Casing Type c)Q C Thanes: 100(.v
Casing Depth: U reptir .
Diameter: La
Drive Shoe:
GPM :5