GW1--03172_Well Construction - GW1_20240524

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Rex Meadows 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2113-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(If applicable)
FROM TO DIAMETER THICKNESS __ MATERIAL
Clearwater Well Drilling Inc. I rt. i 0 fL Let S';n. n ,
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop) f "�
FROM TO DIAMETER THICKNESS MATERIAL '
2.Well Construction Permit#: ft. ft. in.
List all applicable well construction permits(i.e.County,State.Variance.etc.) -- --f
ft. ft. in.
3.Well Use(check well use): i7.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipaUPublic R ft. in.
OGeothemtal(Heating/Cooling Supply) Residential Water Supply(single) II. it. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Cl Irrigation 1 ft. ap ft. 1l lK r\ N- 1�(e C 1
Non-Water Supply Well: ELft. `X t `tom
DMonitoring DRecovery _
Injection Well: it. ft.
['Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicabi,
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier it. ' ft.
❑Aquifer Test ❑Stormwater Drainage ft ft —
OEXperimen[al Technology QSubsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
OGeothetmal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock mgt.,grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) , it. `O3 ft- S(2 t' Y.1 'V L
4,Date Well(s)Completed: `N
y_Ct _24 ell ID# .1.�ft. an ft. L,il
2 G 5`1-1 it. 5�1' ft. (,1�'�ai_cp
5a.Well Location: 1���5
t�aqn �E o«.c m s U-c s��ft. pysft. c � e
ft. it.
.... ..">`...t ,. ,._.. .,"--
Facility/Owner Name Facility ID#(if applicable)
,91Q 4CO k**- 2 t(-..())e Mai Shet,U ft. ft.
Y 2/. 2024
Physical Address,City,and Zip k)C, 21.REMARKS in , ,.r.N 1
Cur IS00 _.k,
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22. a 'fication:
(if well field,one tatilong is sufficient)
Sig lure of.Em ell Contractor Date
6.Is(are)the well(s): iXPermanent or OTemporary By signing this form.I hereby certij•that the we/4c!uns(were)constructed in accordance
with I5A 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 well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 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 attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one jhros Li SUBMITTAL iNSTUCTIONS
9.Total well depth below land surface: Li.Lt J (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiJjerent(example-3ra.2000'and
��2(000') construction to the following:
10.Static water level below top of casing: (l2V (fL) Division of Water Quality,Information Processing Unit,
llJ water level is above casing,ruse"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I l'nn
I I.Borehole diameter: l. I1 7
) (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
`�,lJ tan,
above, also submit a copy of this form within 30 days of completion of well
{12,Well construction method: ta �,( 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 2 7699-1 63 6
13a.Yield(gpm) J Method of test: 24c.For Water Supply&Injection Wells: in addition to sending the formto
1�� 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.
Form OW.I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

Well Driller SoIt Grout Cord n
;ld
ozo sU-C New Weu:___ ---
Owner: Q i GtC,(, �--
tax;
t hereby certify that the above mooed well vac grouted in appearance in accordance with
all County Well mks.
well.Driller: cS signed:
13-f Daae.c�u : ay
Cetrlilicate#:.Z
Construction. Grout:
Total Depth:
Casing, : C Thic_lmess:
Drive Shoe:
Grlvt: S