GW1--04124_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple welts
1.Well Contractor Information:
Rex Meadows 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name H. n•
2113-A ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(If app[[esble)
FROM TO DIAMETER _ THICKNESS MATERIAL
Clearwater Well Drilling Inc. ft. 8` n. j, - in. �VC
Company Name 16.INNER CA81)VG OR TUBING(geothermal closed-loop)
.2Oo�3 - OoS3Q' FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: rt. n. is
list all applicable urni construction permits(I.e.Cow sty,State.Variance.etc) ,
ft. ft. in.
3.Well Use(check well use): 17.SCREEN —
Water Supply Well: i FROM _ TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural oM nicipal/Public ft. ft. in.
u
°Geothermal(Heating/Cooling Supply) tiResidcntial Water Supply(single) ft. 2 in.
Otndustrial/Conuuercial ❑Residential Water Supply(shared) 18. ROUT
FROMG TO MATERIAl. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: it. ,,C V gr. e e/i f fill'A l/j
ft. ft.
N
°Monitoring ❑Recovery
Injection Well: tt. R.
°Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if spptica le)
FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
°Aquifer Test OStormwater Drainage
It. It.
O Experimental Technology °Subsidence Control
20.DRILLING LOG(attach additional sheets It necessary)
°Geothermal(Closed Loop) (.]Tracer FROM TO l DESCRIPT ION(Moe,hardness,saDtroak gpte train sue,roe.)
,°Geothermal(Heating/Cooling Re turn) ❑Other(explain under#21 Remarks) / R• gy ft. J / v.. [j',p 7L
4.Date Well(s)Completed:(f!-J 7'2/we9 tD# lvG/
l�ri�� �� �utii"GC
Sa. �I tiDn: Cep �i �db 4,� zos t l
I uc an LQ,I R R. 9t4i '
Facility/Owner Name Facility(DO(ifappliable) (L ft. M.. / )
4147 (3ra, d fieWW it, 4/ei(a/1 c« ft. ft. 1 2 1024
Phya' Address,City,mod Zip A/C 21.REMARKS
County Parcel[dentifieatio°No.(PiN) ;ACT,j
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: /
(if well field,one latllong is sufficient) r r !/ V
y ',S?9 N3f lc& W --Lb -/9
Signatl7re ofCatifted orrnactor Date
6.Is(are)the well(s): j1(Permanent or [Temporary gy signing this form.1 hereby certify that the wie/I(s)sos(nere)canon led in accordance
with 1 Sd WAG*02C.0100 or 1 SA NCAC'02C.0200 Well Constructiot,Simu/ardr and that a
7.Is this a repair to an existing well: ❑Yes or ANo copy of this record has been provided to the Mel!owner.
!f this is o repair.fill au(known well construction infrtrmatlan 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 also attach additional pages if necessary.
For multiple Infection or non-tomer supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL iNSTUC11ONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Fur multiple wells list all depths lfdifferent(example-3V00'and 2@l00') construction to the following:
10.Static water level below top of casing: (�G (ft.) Division of Water Quality,information Processing Unit,
If Moser level is attire casing,nse"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ` ,! (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
rotary above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOlit WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
f-- ,l()/t 3 24c.For Water Supply&Injection Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: 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 GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013