GW1--03681_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 FRWATER
ZONES
DESCRIPTION
Well Contractor Name ft. ft.
2113-A It. It.
NC Well Contractor Certification Number 15.OUTER CASING(foe multi-cased wells)OR LINER(if a hidbl
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. ' rt. 0 ft. LQ' in. PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
�t^.' 1 l ` C.. _ \ FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: yl�'irAvfir� L13 U t t ) fL ft. in.
List all applicable well construction permits(i.e.County.State,Variance.etc.)
ft. ft.
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) B' ft' in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO
/�MAATEERIAALLj EMPLACEMENT METHOD&AMOUNT
❑irrigation ' R, &O it. C.-6 l 1- ci-1 ,/� .CO_ 6
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
injection Well: H. It.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
0 Aquifer Storage and Recovery OSalinity Barrier ft. H.
❑Aquifer Test ❑Stormwater Drainage
D. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets H necessary)
❑Geothermal(Closed Loop) OTracer -FROM TO DESCRIPTION Woe,hardness,so`lVrock type,grain size,eta.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 021 Remarks) k B• .0 R' c� L 1X (- t`- 1ty
4.Date Well(s)Corn Ieted V�13�� Well ID# e, f ()It O fi '©i..fI t_-c.
�roW1 1 �li ' it. ( (( n ft. C' �/► LJc.
5a. ell Location: t 2i .0D;t. -',��`��\Sn. v `�
6 v-um 1 i ct '1 ISICTft. J ft. i _ -.I, L' '✓h LJ
Facility/Owner Name Facility ID#(if applicable) `ti...`!
40 - P cxie. , \V• , ft. it. JUN 1 8 2024
Physical Address.City,and Zip 21.REMARKS
f f i J Us-LOCI irdi9;xu i%w`•:.ate .. Unit
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cer'motion:
(if well field,one Iatl sufficient)long is su
r ' 3 \L N S101\' 5Ia W --7,.. - o-ay�
Si tore of Cerufied Well Contractor Date
6.Is(are)the well(s):)ermanent or OTemporary By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
with I SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or tlo copy of this record has been provided to the well owner.
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 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. - t� SUBMITTAL iNSTUCTIONS
I
9.Total well depth below land surface: 1 v�3 (ft.) 24a. For All Wells: Submit this form within 30 days or completion of well
For multiple wells list all depths if different(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: LO 0 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use•'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: Lt2 ' -15. (in.) 24b.For Injection Wells: in addition to sending the form to the address in 24a
n n above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: "l )"k -`, 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) CD Method of test: Q- t 24c.ForWater Sunaly&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 Amount: completion of well construction to the county health department of the county
t1�' where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

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