GW1--03680_Well Construction - GW1_20240618

WELL CONSTRUCTION RECORD For internal Use ONLY:
This farm 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 mufti-eased wells)OR LINER(if specabk)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. ft qiJ ft. 3-,tll<.�in.
i
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
/,^ 351 v\i FROM TO U{AMET.R THICKNESS MATERIAL
2.Well Construction Permit#: I )►fly' ft. ft. in
List all applicable'tell 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, SI.OT SIZE THICKNESS MATERIAL
ft. ft in.-
cAgricultural 0 Municipal/Public
❑Geothermal(Heating/Cooling Supply) [Residential Water Supply(single) ft. ft. in.
0 Industrial/Commercial DResidential Water Supply(shared) IS.GROUT
FROM TO
�^� MATERIAL EMPLACEMENT METHOD AAMOUNT
❑Irrigation f R. r1 V " "'Jinn- 1-./'�` I/ n .n
Non-Water Supply Well: I 7� j K-� 11 ) 1 ) ILY L�
fl. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery 0 Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
-
ft. tt.
DExperimental Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets If accessary)
❑Geothermal(Closed Loop) ❑Tracer FRost re DESCRIPTION(enter.bantaess,soli/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return)et ❑Other(explain under#21 Remarks) , ft. -fU ft. c() 1��/`( s _ (AA'0-
4.Date Well(s)Completed:5_v LI Well ID# �,0 f. , C 1f. Jt1vv( 1)A
(9Cat ;?03" cg eAA. Lk,
5a.Well Location: ,90,3ft aq e
- Ye
\-tu,d A-rm- ►c�Ad ft. B.
Facility/Owner Name Facility ID#(if applicable) ft. ft. 4�,•16._.$...- t ,„
CA Q C' uivn 1\C ft. 2 JUN 1 62074
Physical Address,C. and Zip 21.REMARKS
County Parcel Identification No.(PiN) `
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22;Certi session:
(if well field,one lat/lone is sufficient)
r
35` 95' 3� i N 8a � 93-7 W _ 5-, 1 -)tt
Si of citified We l ontr for I Date
6.Is(are)the well(s):F}, Permanent or ❑Temporary Br signing this fort''.1 hereby cern f'chat the nell(s)was(were)constructed in accordance
with 15.4 NC AC 02C.0100 or 15.4 rVCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ,KNo copy of this record has been provided to the styli under.
If this is a repair,fill out known well construction information and explain the nature of the
repair under.#21 remarks section or on the hock 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
S.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 sante construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (- I ) (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple hells list all depths ifdii/erent(example-3@200'and 24_1;1001 construction to the following:
ur-.2
10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
!fniter level is above casing,roe"+" I � 1617 Mail Service Center,Raleigh,NC 27699-1617
1
el
11.Borehole diameter: ` (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
L above, also submit a copy of this form within 30 days of completion of well
Y
12.Well construction method: I U�1 Ct.Y I 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) 5 Method of test: (2 i C! 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.
Fonn GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

Well Driller Self-Grout Certification
Owner New �__--
�., Rehr
I hereby certify that the above teferenced well wlot grouted in appearance in accordance with
all County Well rules.
C.�.�'._-_. Signed:
Well miller: $1
certificate#: .Groutod'
Construction: Grout:
Tory a 5 Type:_ Cenp t-
Casing : Pv c Thickness: mCasing Depth: _
q"°
nlamerer: V)
Drive shoe:
GPM: 15