GW1--03199_Well Construction - GW1_20240524

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
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)
Clearwater Well Driliin Inc. FROM TO++�� DIAMETER THICKNESS MATERIAL
9 I ft. L�V ft. 02 ' in .v
Company Name ^ 16.INNER CASING OR TUBING
r}� _ 1 FROM TOothermat dosed-loop) 1
2.Well Construction Permit#: ,-. v 'Y- DIAMETER THICKNESS MATERIAL
it. fr. hi.
List all applicable well canstr coon permits(Le.County.State.Variance,etc.)
3.Well Use(check well use): ft• ft. is `
17.SCREEN — i
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public it• it, in.
OGeothemial(Heating,/Cooling Supply) IDIResidenhal Water Supply(single) ft• fi• In,
\
CIIndustrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
❑I1TlgatlOn FROM TO MATEIRIA.L EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 1 ft. '•v1 ) iL . m; 6
V1�(.y�(' l�
❑Monitoring ❑Recovery ft. n
Injection Well: ft, it.
DAquifer Recharge OGroundwater Rernediation 19.SAND/GRAVEL PACK If a lice
FROM TO ( PP
DAquifer Storage and Recovery pSalinity Barrier RIATEI1IAL EMPLACEMENT METHOD
i]Aquifer Test ❑St ft it.
ormwater Drainage —
f7Experimental Technologyft• ft.
❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer
FROM TO DESCRIPTION(color hardness,sollrockh
❑Geothermal(Heating/Cooling Ry�etIurn) ❑Other(explain under#21 Remarks) ` ri• l�.Q� ft. E C 1 �,1' r t"'F"to:t:`,er`,1
4.Date Well(s)Completed:J-_`I-"�9' Well ID# ll.V ft ldt"l I ng• -arm CIA
5a.Well Location: iC-
9.9V. �I �``j1 ft (Q t LA
(yanl t
(ti � �� � IL -Itk5ft. 11I
ft. it.
Facitity:Ow(tx�r Name Facility IDa(if applicable) l
343 Q y'� G c��t'I , c,,e >'tC,- n. —
ft. ft. . MAY 2 z 7p24
Ph sical Address,City,and Zip , 1 L.-
1
� V _, tv 21.REMARKS - .....
County Parcel Identification No.(PiN) '-
5b.Latitude and Longitude in degrees/rninutes/seconds or decimal degrees:
(if well field,one hit/long is sufficient) 22. a cation:
' -' 35' 65 N a" Hip" a Li-' w �. _ q -q -a4
r Sig ore of Certified Well Contractor Date
6.is(are)the well(s): t Permanent or aremporary
By signing this form. I hereby certifi than the urll(sl our(urre/constructed in accordance
with 1 SA NCAC 02C.0100 or 15A NCAC(DC.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: LDYes or No copy of this record has been provided to the npll miner.
If this iv a repair,fill out known well construction information and escplaln the nature of the
repair under 021 remarks section or on the lack 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 nay-water supply wells ONLY with the same construction,you can
submit one farm.
SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: "1 LP J (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple arlhs list all depths if different(example-Yp,200'and 2(d100') construction to the following:
10.Static water level below top of casing: VDU (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,the"+'•1 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: CO (io•) 24b. 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
v
12.Well construction method: 1 ofecr ,' 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
13a.Yield(gpm) Method of test: I�q 24e.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-1 North Carolina Department of Fnvironment and Natural Resources-Division of Water Quality Revised lam.2013