GW1--03202_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 a Ilcable
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. ; ft. 7 i ft. lI'''iS, in. pvc -
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
�;s/� - � l' FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: (. / ICI
ft. ft. in.
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.
ft. ft. in.
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) t*esidential Water Supply(single) H. It. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
itROt+I TO MATERIAL EMPLACEMENT METHOD&AMOUNT 1
❑Irrigation
Non-Water Supply Well: / II- al) I.L. C en! /
L im)41
ft. ft.
Monitoring ❑Recovery
Injection Well: ft. ft.
OAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Of applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery DSalinity Barrier ft. H. -
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color.hardness,soil/rock type,groin size,etc.)
❑Geothermal(Heating/Cooling Return)' �j❑Other(explain under#21 Remarks) / ft. 77 ft. Sara , - `,4
4.Date Well(s)Completed:4'�n."niI Well ID# 1.7 rt. (9/2 rt. 21,72.14U iC
5a.Well Location: 8!'()(.v/1 gaV�;i� l[J(rne S �,, rt. (213 ft. o a
l ienV l II P. gogt rs 913 R• ap5 n. (.�rGt d?i�f
Facility/Owner Name Facility ID#(if applicable) J
ft. ft. r.-
a40 fief l(/ 6r_ Le�c51--cr, AIC ft. ft. <..r ;�
Physical Address,City,atrU Zip 21.REMARKS ML Y Rt. 1024
Poncornhe
County Parcel Identification No.(PIN) irr, .?s .'r i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: Gtr> -U
(if well field,one lat/long is sufficient) 22.Cer•tcatio
35. 39 ' 44-r7 N t 4 3 r O7it W 4--,2W-d
Signatur Certified Well Contractor Date
6.Is(arc)the well(s): KPermanent or ❑"Cemporary it),signing this limn.I hereby cerlh'that the well(s)was(were)constructed in accordance
with!SA NCAC 02C.0100 or/5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or g,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 native of the
repair under#21 remarks section or on the back 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 call
submit one form. / SUBMITTAL INSTUCTIONS
5. k
9.Total well depth below land surface: o5 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(e.vample-3(d,200"and 2@l00') construction to the following:
10.Static water level below top of casing: &20 (ft.) Division of Water Quality,Information Processing Unit,
if water level is above casing,use..+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1
11.Borehole diameter: CC /0 (in.) 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
12.Well construction method: f Dy 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) 24c.For Water Supply&Injection Wells: In addition to sendingthe form to
U Method of test: j 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 G W-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013