GW1--03177_Well Construction - GW1_20240524

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells L
1.Well Contractor Information:
Rex Meadows 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2113-A It. ft.
NC Well Contractor Certification Number 15.OUTER CASING(tor multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. \ ft. ip3 ft. I ' in. Pv C.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable wet!construction permits(i.e.County,State.Variance,etc.) -- - -
ft. It. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE. THICKNESS MATERIAL
rt. ft. in.
❑Agricultural ❑Municipal/Public _
❑Geothermal(Heating/Cooling Supply) KResidential Water Supply(single) H, ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT ME HOD&AMOUNT
❑Irrigation I ft. 9 0 ft. �(�(j 0 f}- 'C l` iqi (
Non-Water Supply Well: C 1 I�l l 1 l t )"t
ft. ft.
0 Monitoring ❑Recovery
•
injection Well: R. It.
['Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicabis)
FROM TO MATERIAL EMPLACEMENT METHOD
Cl Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
-
n. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soilrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) \ ft. { /')'� It. sox,, 0 y,., flj (1__4.Date Well(s)Completed:L\ -2.4 Well ID# �� ft (pi 1 10e �i ran t }� �1
---euia 9
.Well Location: a4�y `k- An y'ull o-4-I 0 ft. •S-ft. f ia.ILLIC
�-,��
Dcdd. C1ns ft. ft. '._ ��.1 ki . IL/
Facility/Owner Name Facility ID#(if applicable)
ft. ft. VIAY 2/ 2024
i l i 1,1`11S e - Fat-n-, Drive ft. H.
Physical Address,City,and Zip b i 21.REMARKS ' �`,
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: L2. Z
ation:
(if well field,one lat/long is sufficient)Q Q�1 �1 1 / 7
35 . c• _k 1 N U rX t J I ' Z 11 - W i - lJ=G J
SignCertified Well Contractor Date
6.Is(are)the well(s): 4Pernianent or ❑Temporary By signing this fart, I hereby cert/'that the nrll(s)was(were)constructed in accordance
with I5A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Vo 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 ojthe
repair under 112/remarks section or on the hack of this form. 23.Site diagram or additional well details:
You may use the back of this page :o 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 form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 3.C.);J (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple Hells list all depths if different(example-3C200'and 2ja•100) construction to the following:
0.Static water level below top of casing 0 (ft.) Division of Water Quality,Information Processing Unit,
/f water level is above casing,use"+'. 1 1617 Mail Service Center,Raleigh,NC 27699-1617
R
11.Borehole diameter: (...2I v (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
// j�� above, also submit a copy of this form within 30 days of completion of well
(�' U
12.Well construction method: I lam) 1 tk.,( 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
Method of test: Lk
13a.Yield(gpm) CI 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
completion of well construction to the county health department of the county
13b.Disinfection type: Amount: where constructed.