GW1--03694_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.
NCWell Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if a..tRabic)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. (/ ft. 70 ft. (P7 - in. Pv%
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
/ /}�� l', FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: -; O ?3 ' X J/C. ft. ft. in.
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.
DAgricultural °Municipal/Public
OGeothermal(Heating/Cooling Supply) Residential Water Supply(single) it. it• in.-
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[Irrigation / rt. 0 ft- IP-Mefif m/- {7 ci
Non-Water Supply Well:
ft. ft.
L7 Mon itori ng ❑Recovery
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 °Stormwater Drainage
-
ft. ft.
°Experimental Technology °Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
°Geothenmal(Closed Loop) ❑Tracer FROM TO DESCRIFTION(color,hardness,wlllrock tspe,grain she,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ( ft• ''7� ft. c_X(�y�)/Y / (J Y f
5 .0 0 0 ft. 517 IL ar tr�li�(j Yf�
4.Date Well(s)Completed. `-' Well ID# �` �i p"-r `-
5/'7ft. 5/Q ft. �C,iy/
5a.Well Location: 5/ rt. T-ft n 1, iA6e
L347ta i ourz-- O ft. ft- C� 1JJ �4, {
Facility/Ow�`Name Facility ID#(if applicable) ft ft. '` y L.
�(f 15/ ock /q Dr. f'1i20t/&i4116 ft. ' it. `„ 81.O2
PhPirn1omh
scal Addres,City,and Zip / /UG 21.REMARKS
6 tatisiftil' _
County Parcel Identification No_(PiN) pf ')�,lr
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: ''
22.�tca
(if well field,one laVlong is sufficient)
--37S 757 N 3(0 /Ca,F W / 5- 36 .-.-Al
Sig a of Certified Well Contractor Date
6.Is(are)the well(s): Permanent or [Temporary By.sign ng this form. I hereby cert(lle that the well(s)was(were)constructed in accordance
with 15d;1C4C 02C.0100 or 15.4 NC.IC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or )No copy of this record has been provided to the well 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 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 alsc.attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. /�/J SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (i �/5- (IL) 24a. For All Wells: Submit this fours within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3ra�200'and 2@100') construction to the following:
10.Static water level below top of casing: (Y U (ft.) Division of Water Quality,information Processing Unit,
If miter level is above causing,lac"+" 1 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: C_(/ 4 (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
L
12.Well construction method: KO / ar y 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 2 769 9-1 636
13a.Yield(gpm) Method of test: /2/9 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-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

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