GW1--03667_Well Construction - GW1_20240618

WELL CONSTRUCTION RECORD For Intermit 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. R.
2113-A ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for mohi-eased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. / ft. Li f ft. 6 r Alin. -
Company Name 16.INNER CASING OR TUBING(geatltcrmal dosed-loop) /
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. ht.
List all applicable well construction permits(i.e.County,State.Variance,etc.)
ft. ft. is
3.Well Use(check welt use): I7.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural °MunicipaL/Public
°Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. It. in.
0Industrial/Commercial °Residential Water Supply(shared) t IS.GROUT
FROFt TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation fl. �y�/y�" �. Zvi
Non-Water Supply Well: / 2 �� C C�/ !t;/(,/ //// Q�
n. ft.
❑Monitoring ❑Recovery
Injection Well: ft. R.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage _
ft. ft.
❑Experimental Technology °Subsidence Control _
20.DRILLING LOC(attach additional sheets If necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(tiler,trod satur.etr type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) / /t. Li'O • �LCA )d j j-
3eill ft ft ryt ,N i
4.DateWell(s)Completeds Welltg)# .�// R. �`� R G4�C/// ,
Ss.Well Location: ����(/t
% lone 4- Lctrni h'u i sin r >3i a R. C38S ft.it- /�
R. R.
Facility/Owner Name Facility iD/f(ifa 'able) II. j\JE%
h/esf Qd Poi Ste. s R. �TC-r
Physical Address.City,and Zip 21.REMARI(S hi 1 82024
Pa d1 scn
County Parcel Identification No.(PIN) pert, ++'R t'-K:v4e-.t U -
� [Ttica _
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.f:erti£ ation•
(if well field,one lattlong is sufficient)
35. 98 ' 09E N ,? 5i 30W W /t—
SignaSul of Certified Well Contractor Date
6.Is(are)the well(s):XPermanent or °Temporary
Br signing this force,I hereby cerlI6,that the well(s)was(were)constructed in accordance
with 1 SA WAG 02C.0100 or ISd NCAC 02C.0200 Well Construction Slain and that a
7.Is this a repair to an existing well: °Yes or ii o copy ofrhis record has been prorTided to Lie well owner.
If this is a repair.fill out known well construction information and xplain the nature 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 ran
submit oneform, SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: c.S'5 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all deptkr ifd/erenr(example-3Ca.200'and 2 f 1001 construction to the following:
10.Static water level below top of casing: (.. �/l
(ft.) Division of Water Quality,information Processing Unit,
if water level is abort casing,use"+"i j 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (f /s (in.) 24b.for Injection Wets: 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: r 0 'Plli 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 2 769 9-1 636
I 3a.Yield(gpm) 7 Method of test: F� 4 24c.For Water Supply&Iniecton Wells: In addition to sending the form to
y< the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ��ari/ /if Amount: S ��itc completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources--Division of Water Quality Revised Jan.2013

Wall Mier 11.1116411roat coltifketion
•
MLA/SIX:um V
ter: aff f mG sepaht
Permit
I hereby certify that the above mooed well was gated in appettonce raevaith
all C imty Well rules.
Weil Driller_ rJ/X /1401/W-f S'
Certificate#: Zl 13" 4- naee -
, �3
Construction emu:
Tom► ; . Type: ()er
Casing Type: pie- Thiclatss:
Casing : IR __QO
Diameter: n
VVelgbtJ nlic1
Height
Dive e Shoe _
GPM:_