GW1--03665_Well Construction - GW1_20240618

WELL CONSTRUCTION RECORD For Interval Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
14.WATER ZONES
Rex Meadows FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2113-A "- ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased welly OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. i ft. Lk U ft. in. Si-c, _ I
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 well constntction permits(i.e.County,Store.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 ❑Municipal/Public _
❑Geotheal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
rm
❑lndustrialiContmert:ial ❑Residential Water Supply(shared) LIL GROUT
FROST TO MATERIAL
n..�. EMPLACEMENT METHOD&AMOUNT
❑Irrigation i fL , (,1 ft `C.(1 lX.�'l,tl 1 1 �t i><••x-!
Non-Water Supply Well:
«- ft.
OMonitoring ❑Recovery
-
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. It.
❑Aquifer Test ❑Stormwater Drainage
ft. H.
❑Experimental Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
DGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION� (color.Sudeten.soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1l h' 4c�Ip IL t, { )C-.` " c."-�(
t.
4.Date Well(s)Completed Z4 Well 1D# {TU it. l)Q1E t ,r-Guu
ft. ft.
5a.Well Location: ft. R.
+-l°vjeT) Pa) 1.-\ma ft. n.
Facility/Owner Name Facility 1D9(if applicable) ft. ft.
\ \a\ \-A"L t C Gore 1 . �/ ii t
ft. ft.
Physical Address,City,and Zip t t Sp(")ir.,1 S ),)L 21.REMARKS a ] 8 2024
\lochs On
County
Parcel identification No.(PIN) lrofof Aff'1 4r'..1#0#.-4 UBE
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22:Cer ftcation•
(if well field,one latticing is sufficient)
3,- 43 ► 9'-' N S)%' 5C) . 5Ck 4- W - ti\ -zy
Sig of Certified Well Contractor Date
6.Is(are)the well(s): Permanent or OTemporary gy signing this form,1 herein certify'that the well(s)nos(were)constructed in accordance
with 15A NCAC 02C_0100 or 154 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: [Wes or t Go copy alibis record has been provided to the well owner.
If this is o repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or an 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 can SUBMITTAL iNSTUCTIONS
submit one form. (f���_
9.Total well depth below land surface: V.) (ft.) 24a. For All Wells: Submit this tom within 30 days of completion of well
For multiple wells list all depths ifdijferent(erample-3`200'and?(d;100') construction to the following.
10.Static water level below top of casing: I(,)L.-' (IL) Division of Water Quality,Information Processing Unit,
if wider level is above casing,use"+- 1617 Mail Service Center,Raleigh,NC 27699-1617
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d
11.Borehole diameter: i - (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
1 above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ILt CL t i( construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
1 FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 636
1 t i 24c.For Water Supply&injection Wells: In addition to sending the form to
13a.Yield(gpm) Method of test:__ 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 GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Ian.2013

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