GW1--03169_Well Construction - GW1_20240524

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY: I
1.Well Contractor Information:
• Rex Meadows 14.WATER ZONES
FROM TO DESCRIPTION Well Contractor Name - ft., ft
2113-A ft. ' ft,
NC Well Contractor Cenification Number 15.OUTER CASING(for multi-eased we1219R LINER(If applicable)
FROM kip
DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. ft. ft. ICc)iI , ,
Company Name I6.INNER CASINO OR TUBING geothermal dosed-loop) ���
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable nell construction permits(cc.County.State.Variance.etc.)
n. ft. in.
3.Well Use(check well use):
17.SCREEN —
-
WaterSupplyWell: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑A nculturai ft. ft. in.
g ClMunicipal/Pubhc
❑Geothermal(Heating/Cooling Supply) iesidentiai Water Supply(single) ft ft. in.
❑Industrial/Commercial /❑Residential Water Supply(shared) la GROUT
FROM TO MATERIAL EMPLACEMENT ETHOD&AMOUNT
❑Irrigation
; R. R. ��1 t ��� 9�,5CIl
Non-Water Supply Well: v M t 1C
❑Monitoring l7Recov ft. ft•
Injection Well: ft. ft. -
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(If applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test DStormwater Drainage
It. ft.
OExperimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)OGeothermal(Closed Loop) OTracer
FROM TO DESCRIPTION cuter hardness,son/rock type,gala stze.rte.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I ft. 3 �m ft. „/l(r/��( 17 /� r
VC
4.Date Well(s)Completed:" i tY) l `Well ID# (� it I`�R. lx raj_C[ �✓�
40 ft. 7 .-1
f ft /,r , t , d
Sa.Well Location: n ft. / 5 ft. �` n It
CD\\ PYl Car / 1`
ft. ft.
F Iity/Owner Name�1 q.a Facility IDa(if opplicable)
C�'� �1( � ft. R.
ft. ft.
Physrrrccc i Atklress,City,and Zip ({�AY 2 - r(2¢
�/► 1��j',� „ \� 21.REMARKS
lv//' •Ji'4
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: C if cation•
(if well field,one latilong is sufficient)
36- ' 3' 0 N S,q ` \ ' .-3 3 i W ,i- J 4 -2 'a 4
Sig t of Cenifi it Contractor Date
6.Is(are)the well(s): errnanent or ❑Temporary By signing this form. 1 hereby certify that the ue/l(s)um-(were)constructed in accordance
1/ with 15A NCAC 02C.0100 or 15.4 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 neR owner.
I f this•is a repair,fill out knoun well construction information and explain the nature of Me
repair wider#2!remarks section or on the hack of tltisftum. 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 iron-inter supply wells ONLY with the same construction,Mnr can
submit one linnet. SUBMITTAL iNSTUCTIONS
1
9.Total well depth below land surface: ( 5 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple twits list all depths if d fferent(example-3@100'mid 2(000') construction to the following:
10.Static water level below top of casing: UX U (ft,) Division of Water Quality,information Processing Unit,
iJhntcr level is ahote casing,cue"{�" ( , 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: U� ' (in.) 246, 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: rUall 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
/� 24c.For Water Suppit&Injector Wells: in addition to sendin the form to
13a.Yield(gpm) �' Method of test: �(/� g
the addresses) 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(IW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

Wadi MOW $IW 4ilr' C.rdtiu en
Ovvner:.0
New Well:__ --, - -
Pettnit
I hereby certify that the ads re£ e�locl well wFa4 grotit�ed in a le a OC with
all County Well rules.
/�p
Well Deiller; ( K M` ` `"S
Certie#: a V\ - name c : 4-LLP -aq
Cnnst rud1c Gm*:
Total Depth; 005 TY1e:
Casing Thickness: Sill yAr
W
Di : i.
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