GW1--03679_Well Construction - GW1_20240618

SC-
WELL CONSTRUCTION RECORD For Internal 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. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if op livable)
FROM TO DIAMETER THICKNESS MATERIAL.
Clearwater Well Drilling Inc. 4 ft. 1\3
ft. 62 15c'• in. \C
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: G a1�0��) FROM ft TO iL DIA)tETE R In. THICKNESS MATERIAL
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 ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) rt. ft. in._
❑Industrial/Commercial ❑Residential Water Supply(shared) 18. RO
FROMG UT TO MATERIAL
fit' EMPLACEMENT�METHOD&AMOUNT
❑Irrigation ` n �'lrf ft. ett 1 )d11lt 1 1lt�X( I
Non-Water Supply Well: C7
It. It,
❑Monitoring ❑Recovery
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATER7.SL EMPLACEMENT METHOD
OAquifer Storage and Recovery OSalinity Barrier ft. ft.
❑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,sail/rock type,grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) t ft. 1`-2 IL /It ry • CI(Y--
4.Date Wel1(s)Completed:5 2Z--Zia 1D# `3 ft- - .\ ft (�Ak--(11t\\
�1 ft. 31� ft. x I Lk,
5a.Well Location: 3\ ft. J ft- �p
, { 1 nuSe ft. n. ���1 `r-t- a
�
Facility/Owner Nam Facility ID#(if applicable) ft. ft.. f '►�`.rtr.� 1...4
11G CIeif,m - - 1 . ft. ft. JUN 1 8 2024
Physical heyssiicall Address,City,,aand Zip 21.REMARKS
County 1 Parcel Identification No.(PIN) 1 ANC$104
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: Cer ficatio t
Orwell field,one he'long is cuff dent) t
51 4 . 0S� N Sty � ) ZD-7 W / 5-30 -Z4
Sig -of Certified Well Contractor Date
6.Is(are)the well(s):permanent or ❑Temporary gv signing this form.I hereby certify that the well(s)was(acre)constructed in accordance
with/5A NC IC 02C.0100 or 15.1 NCAC 02C.0200 Well Construction Standards and that a
7.1s this a repair to an existing well: ❑Yes or cN copy of this record has been provided to the well owner.
If this is a repair.fill out known well construction in onnation and lain the nature of the
repair under#21 remarks section or on the hack 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 v.-ells ONLY with the sante construction,you can
submit one form. SUBMITTAL iNSTUCTIONS
9.Total well depth below land surface: l'N-Y3 (Ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple Hells list all depths if-different(example-3rig(200'and 2g,J00') construction to the following:
10.Static water level below top of casing- LOl-) (ft.) Division of Water Quality,Information Processing Unit,
IJitter level is above ceasing,use"+" l 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: l O 1 .
(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: 1
1�O i`-( construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gym) Method of test: 0 IC\ 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
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 Jan.2013

Carlifkatkon
w
INN! PROW
Owner LYS-
I hereby certify that the above referenced well,waa grouted in appearance its accardtpnoe wNh
all County Well rules.
well Driller: Meciciocio_s s.
certificate*: l 13-A Dale crow
Construction C4mut
Total Depth:Casing _
Thiess: _
Casing 13
Dlarxemr: Lo
Drive Shoe~
GPM