GW1--04095_Well Construction - GW1_20240712

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
ft. ft.
Well Contractor Name
2113-A It. ft.
IS.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
NC Well Contractor Certification Number FROM TO l DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. I ft. (4.„? ft.
I (...p 1 K in. /l/C
16.INNER CASING OR TUBING(geothermal closed-loop)
Company Name FROM TO DIAMETER THICKNESS MATERIAL
ft ft. in.
Well Construction Permit fit
List all applicable well construction permits(i.e.County,State. Variance,etc.) ft ft. iis,
3.Well Use(check well use): 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Water Supply Well: ft. It. in.
❑Agricultural ❑MunicipaUPublic -
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
❑Residential Water Supply(shared) 1FR GROUT —
❑lndustriaVCommercial FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Itngation 1 R" ec au n. e 'nv Mk tLVet
Non-Water Supply Well: ft. ft. l 1 1 u 1
❑Monitoring ❑Recovery ft. ft.Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable_
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier it. ft.
❑Aquifer Test ❑Stormwater Drainage ft. - ft.
DExperimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiVrockk ' e, rain sine,etc.)
tL C r (t' r ^� l
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) f 7j 5R (il
(AI fL 01 (Arr ' i)e_
4.Date Well(s)Co feted:�(�- -V�-�Z�tWevlll ID# It, t i yC( tt. re ul
5a.Well Location: ,fit v Q'�`��r"I A/r O 1 UV ft. l,�llS JS f t. tt r, 1 ie
V- rA- Qv,1 1C 1<co- .,\ l . C)�-`, ft. ft. J l U i ,. _
Facility/Owner Name (� +' J Facility 104\(if
�,applicable) I ft, ft. -
C) l •�1m L V c tl. Di' . Mans��l I it. ft. .1 ti" r k -' `i t L)
Physical Address,City,and Zip 1\) 21.REMARKS — JUL 1 2024
County Parcel Identification No.(PIN) 3,4
-
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cer' lion:
(if welt field,one lat/lon is sufficient) r - q ,I
,...,, J W I *Signature ertified ell Contractor Date
6.1s(are)the well(s): Permanent or ❑Temporary By signing this form,I hereby certify that the welts)was(were)constructed in accordance
with 15A 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 io copy of this record has been provided to the well owner.
If this is a repair,fill out known we//construction information and explain the nature of the 23.Site diagram or additional well details:
repair under N21 remarks section or on the back of this form. 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 SUBMITTAL INSTUCTIONS
submit one form. /}p
9.Total well depth below land surface: tl (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-30d200'and Now) construction to the following:
�� (ft.) Division of Water Quality,Information Processing Unit,
I w terl is abover level belowg top of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
If water level is truing,use"+'" t
U�j • 24b.For lniection Wells: In addition to sending the form to the address in 24a
11.Borehole diameter: s (1O) above, also submit a copy of this form within 30 days of completion of well
12.Well construction method:
r-U t u( construction to the following.
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY: /�
1/ n 24c.For Water Supply&Injection Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: 1< the address(es) above, also submit one copy of this form within 30 days of
4 �1 3i)a, completion of well construction to the county health department of the county
13b.Disinfection type: '�✓� Amount: [�[1/, where constructed.
Form OW-1
North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

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Address'. ?
Permit;
�accordance with
Iliez' by #Y
that the abovef1CCh well wig grouted in appearance
all County Well toles.
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welt Dxiltrr� D[Me °d'
GrootCoast uction:
Total
Casing -_.Q-\ ---�
Drive
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GPM: 1