GW1--03174_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. / ft. s V R. Lc) in— 1j6
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS _ MATERIAL
2.Well Construction Permit#: ft. ft. is
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
❑A ricultural ft. ft. in.
8 OMunicipaVPublic
riGeothernal(Heating/Cooling Supply) tesideutial Water Supply(single) ft. ft. in.
❑Industrial/Commercial ()Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation R. ft.Non-Water Supply Well: Gel►IC�,( j} �J {.L.�
ft. ft.
[]Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stonnwater Drainage
—
ft. ft.
❑Experimental Technology []Subsidence Control
20.DRILLING LOG(attach additional sheets If necessary)
['Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soilirock t)pr,grain sire,etc.)
❑Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) / ft. 71 ft• ff'U)')O � /
4.Date Well(s)Completed: L .' o� - ``��I'Well ED# ft. tad ft• J ra tipe
5a.Well Location: 690 ft• 06A ft `. �a
n Lou". 705- ft. graft.)k
doll re)1(1 ` - LCtrity
! !�1 Appel-hes hie, ft. ft.
Facility/Owner Name 11' Facility ID#(if applicable) I.. - . - } r .
t-0t R. ft.
7O Mort i n Ares kors-ly If NC ft. ft. MAY 2 2G24
Physical Address,City,and Zip
21.REMARKS
Magus D ) — . .; s�iI
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cectiffe-ati
(if well field,one lat/long is sufficient)
25'45 - d,Q17 N U t 3 = ',),5 W /t___---- y I& d
Signs ertified Well Contractor Date
6.Is(are)the well(s): krermanent or []Temporary
By signing this form.1 hereby certifi,that the wrIl(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 13A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or erNo copy of this record ha,been provided to the led)owner.
If this is a repair.fill out known well construction information an rplain the nature of the
repair under ttZI 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 welts 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 form. SUBMITTAL INSTUCTIONS
9."Total well depth below land surface: IL)5- (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iI different(example-3200'and Zed l00') construction to the following:
10.Static water level below top of casing: (190 (ft.) Division of Water Quality,Information Processing Unit,
if water level is°hone casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: LD /5 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
L above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: rU 1 Ct1-y 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
13n.Yield(gpm) Method of test: el C1 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
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

Wall DdNor SelfmIlhrolutt CHMMos**
Owner: Poi Ijr;41{Lth:OPaigy--P4P New
1 ft
or ri.A T / Repair__
Permit:
I'hereby certify that the above referenced well was grouted in appearance in accordance with
all county Well rules.
well Driller,AekMe()6 CAA.2_,S Siffneit,
Certificate*: 0 I I3 -A- Date Grouted 9-4-$2 lk
construction: Grout
Tond Depttr, 71.0 Type: Cerry-n+
CasingTYPe: PVC Thidmess:
Casing DepthtiLl_ Derth:
Diameter: I? _
Weight/Thick
Height:
Drive Shoe: _
GPM: .