GW1--04906_Well Construction - GW1_20240816

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WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For internal Use ONLY:1.Well Contractor Information:
I
Rex Meadows 14.WATER ZONES
Weil Contractor Name TO DESCRIPTION
R• R.
2113-A ft. ft. _-___
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells OR LINER(f appltcable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc.
f4 ft. 1 t In. 1�Company Name [� 16.INNER CA INC OR TUBING(geothermal closed-loop)
I J` 't
/ ! I�( FROM TO DIAMETER p)
2.Well Construction Permit#: [U lJVV11 i1 ll//VV I :J THICKNESS MATERIAL
List all applicable well constructionft. (L in,
pens/ (fe.Carnnp.State.Variance,etc.)
i
3.Well Use(check well use): ft a. —ITC
17.SCREEN
Water SD _
Supply Wen: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Publie ", In.
❑Geothermal(Heating/Cooling Supply) I k esidential Water Supply(single) ft. In.
Cl industrial/Commercial °Residential Water Supply(shared) t IS•
0lniganon FROMGROUT TO MATERIAL
Non-Water Supply Wen: n , ft. EMP[AcaattsM METHOD&AMOUNT
❑Monitoring °Recovery ft. ft.
Injection Well:
❑Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK r
DAquifer Storage and RecoveryU applkaMo}
❑Salinity Barrier L FROM ". TO ft. MATERIAL EMPLACEMENT METHOD it
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTraco r 20.DRILLING LOG(attach additional sheets if necessary) ,
FROM TO DESCRIPTION(color,hardest,,seWioclt type,Erato■
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. 4' ]t. iz`'etc}
a,Date Wdl(s)Completed:1 a--a 1 Well IDIF Sq- ft. ac6c1 fL () U u j-.
5a.Well Location: 2 C>J Q t�jv 1 iCIC_ S r tiffl � � P_�1 CSC
". "- S' Ciinit
Facility/Owner Name ft. ` ft.
Facility iD8(if applicable)
U4'' Sp;r P.i OCC.c1 6 . W PaI,YXoi tie- ft. fL `•,
real Address,City,and Zip
(� •( Q'J( ���
�.110M.� _21,REMARKS l7
iferati
County 1 Parcel identification No.(PiN) ` `:f'�tt�^ram :' Usk5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: -/ / I �A� �
(if well field,oncre lat/tong is sufficient) 22.Ce fieation:
N c� IIJ � w t -a � a4
Si turn f Certified Welt Contractor Date
6.Is(are)the welt(s):.Permanent or ❑Temporary
By signing,hie form, I hereby car tiff,that the wellw wear(were/constrncrerl in accordance
7.is this a repair to an existing well: Oyes or No With i.1A NCAC 02C.0/00 nr 13,f NCAC 07C.0200 Well Construction Standards and that a
If this is repair,f!h!out known well construction Information and eplain the nature of the copy of this record has been provided to the Hell owner.
repair under#21 remarks rattier or an the hack of this farm.
23.31te 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 constricted: construction details. You may also attach additional pages if necessary.
For multiple injection or non-miter supply wells ONLY with the some contraction,you con
submit one feu. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: ✓ J (ft) 24a.
For multiple Wens list all depths ifdijferem(erample-41)200'and 2 al!o'f For All We following:
Submit this forte, within 30 days of completion of well
C. ) construction to the following:
�D (ft.) Division of Water Quality,Information Processing Unit,
10.Static water level below top of casing:
IJ'tinier level Is above easing,use"+" ` 1617 Mali Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: t�n lJ (in.) 26b. For tniection Wells: In addition to sending the form to the address in 24a
rOL/y 1rl f above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: TL.(�9 construction to the following:
(i.e.auger,rotary,cable,direct posh,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
r
13a.Yield(gpm) i J Method of test: 1 C' 24c.For Wate[Suonly&inlectlon Well .,in addition to sending the form to
the address(cs) 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-I North Carolina Department of Environment arid Natural Resotrlses-Division of Water Quality Revised Jan.2013

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