GW1--03677_Well Construction - GW1_20240618

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-used wells)OR LINER(If ap l cable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. 1 fL l9y ft. U1 it 3 in p\,r,
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
� A �S \ FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit it: N.(1-- 1 1 ft. it. in.
List all applicable well construction permits(f.e.Counry.State.Variance,etc.) - -
ft. ft. la
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
kgricultuwl -.rturt-(1 ❑Municipal/Public ft ft. to
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18. ROUT
FROMG TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation , tL rY,', ft. CQrr` , tin
Non-Water Supply Well: ft. ft. 1 1 t t
❑Monitoring ❑Recovery _
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
0 Aquifer Storage and Recovery ❑Salinity Barrier ft ft,
❑Aquifer Test ❑Stortnwater Drainage ft. ft.
.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTIONWilms,(color, s,wlVrock type,grin size,etc.)
❑Geothermal(Heating/Cooling Return) (❑Other(explain under#21 Remarks) 1 R 1 nU R• .0>1 Jfl( c. 1, ri-
4.Date Wells)Completed: -15 - (Well ID# 11 ft• lf? C ft. 0 u\�t t.
ts ' .1 ft. LOCO ft. t��J,l QJ\.,')i(1.
(S�arQ Ch
.WellnLocstiomO� �OS rt• �rllX,t ti-�'
ii l sko 1 "i it.t ft. ft.
Facility/ Name Facility ID#(if applicable)
.5n Lcw To Ra C.r�. At ) 1.)C, ft.. ":. `��i}
Physical Address,City,and Zip 21.REMARKS i
t N I R 2024
\-4n\(v�uc�c\
County Parcel Identification No.(PIN) irnttj:>:rltvt Z.: •ar4.•;Unit
D'f► .t a;
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: r22. a cation:
(if well field,one lat/lonng is sufficient) h
� ),) CY� 1� N aS i �� 101 W 5-D 3-a y
S. not Certified Well Contractor Date
6.Is(are)the well(s):XPermanent or ❑Temporary By signing this form.I hereby certifj•that the wells)tins(were)constructed in accordance
with 1 5A NCAC 02C.0100 or 1 5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ViNo copy of this 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 on the bock 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
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: Q c3 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple nulls list all depths if dtfjerent(example-W00'and 2@l00') construction to the following:
10.Static water level below top of casing: l!10 (ft.) Division of Water Quality,Information Processing Unit,
Twitter level is above casing,use"+• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: Ul`' CD.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
L 'r above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ro l(,l 11 1 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) 3 Method of test: 3 24e.For Water Supply&loiection 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 Environment and Natural Resources-Division of Water Quality Revised Jan.2013

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