GW1--04120_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:
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 multi-cased wells)O_R LINER(If applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. ' n: WO rt. IQ I I R in. PVC
Company Name _ It INNER CASING OR TUBING(geothermal closed-loop) l '"
anQ� 3 - 5 a 1 F7201! f0 _DIAMETER T711CKYE3s MATERIAL2.Well Construction Permit#: V ft. ft. in. —
List all applicable well construction permits(t.e.County.Stale.Yarimrce•etc.) i
R. fit. la. I-
3.Well Use(check well use): 17.SCREEN j
Water Supply Well: '-- w I�FROM I TO DIAMETER SLOT MEE THICKNESS MAT£Riau'
flAgrieultttral °Municipal'Public ft. It. In.
°Geothermal(Hexting/Coohtlg Supply) ,Residential Water Supply(single) ft' n In.
0 Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
°itri anon TO MATERIAL C
EAIPL EMENT Mr.!ROD&6MOENT
!t. ft. �1/�(Y r L1`[s_J.f_^
Non-Water Supply Welk: �O �....C..l_.!
°Monitoring °Recovery ft. fit.
Injection Well: ft. n
0 qutfer Recharge rLitirourdwater Remediation I r1r
9_Sr.. ND/GRAVEL PACK If livable
0Aquifer Storage and Recovery GSalinity BarrierO-'I 7v T€R I. EMPLACEMENT METHOD
R. �ft.
0A;iuifer Test CStonnwater Drainage t._-__
R. R. 1
❑Experimental Technology °SubsidenceCoutrol �:._._� — _ i
�20.DRll-I,NG LOG(M taee additional stc:cls IIexgcsst-v)
DGcothen al(Closed Loop) °Tracer FP.ou ' av nrtscatPTtost(tvti,,E.rt atlrac:e.:ie:,wr-t t .i
❑Geothctrsal(Heating/Cooling Return) °Other explain ander 421 Rem arks ft. WO R. 1
4.Date Well(s)Completed:W-ICJ -.) veil lDf Pilft JUL,' -.,-
1 A 1L t' of R' 1
Sa.Well Location: �t� s(1A c ion �2 "6 rekAt ------ ---,
P > V U -C ��a�l h. I�S R. aril
lti if e. n. n J __._
Facility/Owner Name Facility ID#(if applicable)
l 1 .9_ CtS.'L�L.. Gz d 1&1.1.L./� (�. ff. t (t. , ,` i�!VEJ
P lent Address.City,and Zip C 21,REMARKS
C_)5-HMC _ _ JUL I 2 Z024
County Parcel tdenti@caton No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: t 22 Cer matron:
(if well field,one lat,long,is sufficient)
S: 411 101 N ?'a 3 2_0 L___w ao 4
igualure ofCerti rador Date
6.Is(are)the t.zil(s):XPermancni or °Tetaporary By signing this form.I hereby verb/l'that the tre)l(s)was(were)constructed in accordance
with 114 NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to ER existing well: D Yes or Ito copy of this record has been provided to the well owner.
Thins.is a repair,fill Mg known well construction ittformaiion caul militia the stature of the
repair under 1t21 remarks section or cn the hack of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional welt site details 01 well
8.Number of wells constructed: ye�_ construction details. You may also attach addiinsrat pages if nee.-s'si'}.
Far multiple injection Of non-miter supply wells ONLY with the same cares+ractinn,you cart
submit one farm- SUBMITTAL INSTi•_t•CTIONS
9.Total well depth below land surface: I J __ (ft.) 24a. For Ali Wells: Submit this fonts within 30 days of completion of well
For moitiplewrits list all depths.fVircot(example,3r'n'000•a�nd:CC10B) construction to the following:
10.Static water level below top of casing: WO (fit.) Division of Water Quality,Information Processing Cait,
Ifwaterlet,l is above casing.use";" 1617 Mail Service Center.Raleigh,NC 27699-1617
t
11.Borehole diameter: V% (in.) 24b.For Injection Welk:: In addition to;emling the ferns to the address in 24a
1 above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: V 1 construction to the following:
(Le.auger,rotary.cable,direct push.etc.)
_ _ Division of Water Quality,Underground injection Control Program,
t�C:'J>T TR SIJP1 LY�WELLS O VLYt 1636 Moil Service Cutter,Raleigh,NC 27699--1636
13s.Yield(gpm) vv Method of test: 24e.For Wing)~S ;stly&lair rots Wells: In addition to sending the form to
- the itetirzss(e-\ :il .T' cue - t- �.y -
" --._-n _:.`:, ?:-•• :?<.C:t;i :_::. `:.:rl Cro :.L;: ?.3?:iri;i:iP- - :lava of
i f3b.Disinfection type:__ Amount: completion of well construction to the county health department of the county
_ " -' _— _,........_. a _ whose constructai.
Form OW-i North Carolina Department of Fnvintnment and Natural Resowcm-r)i.•isinn of Water Qualirs Rvv;w:d Jan-2013

IN 0
.aoug argia
:act,WulsRD
8r :u �
-4-
4019
moVizinxisUJ
Kann
vatria P.M£1urtoJ tie
a3deusxrae R.=mad&Ili paartaii sem Ram pazazaaajaa aglow ag I
_.� - —ARM AaN
"-Vsv'© ,o ff.