GW1--03678_Well Construction - GW1_20240618

WELL CONSTRUCTION RECORD For Internal Use ONLY;
This form can be used for single or multiple welts
1.Well Contractor Information:
Rex Meadows 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. H.
2113-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(If ap ikable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. 1 ft. Lc (.12):3' in. PVC Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
�} FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: J M G. — d� ft. ft. in.
List all applicable well construction permits(ie.County.State.Variance.etc.) R. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. R. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation `i ft
JO ft. /j Q �� �t I
Non-Water Supply Well: l XQ
ft. ft.
❑Monitoring DRecovery
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. ft.
❑Aquifer Test ❑StormwaterDrainage ft. ft.
—
❑Experirnental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION(color,hardness,soiVreek type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) c,/ ft- gu) ft• �(,t,(\ `—di`'-f
4.Date Well(s)Completed) 20`Zy Well ID# OlY ft.
�����4. girt Xti}� i• ` `j r
5a.Well Location: 1 lrtl-1 H ne5 -
JUN2024
(� I 18
v\rtrV Uu► It Ve i Le\A-I ft. _ ft. I Facility/Owner Name Facility lD#(if applicable) intli`141.4 pa wec^2004r
G t� ( oyo�e Noi1ow Rd . R. ft. Ac C- 'irk -to DI unit
Address,City,and Zip "plrQ "�
�!AL I�'30 L\ 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
2 .Cer1i lion,.;
AA(if well field,one tat/long is sufficient) (� 5- 2 2 4
a3" &v r Ul I` N 1 5 1 ' 1 o W �1/ i J
Si are o Certified Well Contractor Date
6.Is(are)the well(s): Xsermanent or ❑Temporary
By signing this form.I hereby certifj•that the arR(s)was(were)constructed in accordance
with ISA NCAC 02C.01 0 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or )io copy of this record has been provided to the aril owner.
If this is a repair.fell out known well construction information and explain 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 can
submit one form. �(r�F�✓ SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: V 0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and2@100') construction to the following:
10.Static water level below top of casing: CO 0 (ft,) Division of Water Quality,Information Processing Unit,
limner level is above casing.use"+"1 r, 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ly 16 (in.) 24b.For Inlection Wells: In addition to sending the form to the address in 24a
/y above, also submit a copy of this form within 30 days of completion of well
V
12.Well construction method: t U F a..I l j 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) 0 Method of test: Q I ij 24c.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 G W-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

on
w.i1 D - C rdega!i
1 r►ru 4 5
owner:Ma- Y-,e t 14 � u - Vs3 New well: R---^---
Addresc
thereby+oeartfythat the above referenced well wiz grouted in appearance 9n accordanr:e with
all county Well rules.
C M eC(c1CA- `
Cect[bca�e#: Dab
Construction: Quit
Tatar Depth T�rlmess: r,��►1 o r�
Casing N-
Casirg Deptb:
Diarnenac 19'1g
Drive shoe: