GW1--04953_Well Construction - GW1_20240816

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
I
I.Well Contractor Information:Rex Meadows14.WATER ZONES
FROM TO DRSCRrPTION
Well Contractor Name ft. I2113-A fti• .
NC Well Contractor Certification Number 15.OUTER CASING(for multi cased wells)OR LINER(if mp foible)
Clearwater Well Drilling Inc. FROM ft TOi4s ft DIAMETER THICKNESS MATERIAL
Company Name (1,+ in.
16.INNER CASING OR TUBING(geothermal dosed_Iooe)
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
ft' It. in.
List all applicable well construction permits(i.e.Colony.StaleVariance,etc.) _
3.Well Use(check welluse): ft. It. —Is.
Water Supply Well: 17,SCREEN -" ,
FROM TO . DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural DMunicipal/Public R rt. is,
❑Geothcmnal(Heating/Cooling Supply)
PPIY(single)
esidential Water Su ft. ft• In.
❑industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT - {
❑1R1ganQtt FROM TO MATERIAL EMPLACEMENT METHOD et.AMOUNT
Non-Water Supply Well: I n• A,-, n. Barr i 1111 >-C cli
DMonitoring ❑Recovery ft. ft.
injection Well: R H
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK
DAquifer Storage and RecoveryR applicable)
❑Salinity Barrio t FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. a.
❑Experimental Technology DSubsidence Control n• TM'
20.DRILLING LOG(attach additional aheets if necessary)
❑Geothermal(Closed Loop) ['Tracer
PROM TO DESCRIPTION(calor,eirdaen,mllAvek type,;rate
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) ( 'r"'etc.)
4,Date Weil(s)Completed: t -10�4 IDSLi- ft. LQ rT ft 1(`�Lr ire
Sa.Well Location: Si-an °4- Debbie, atA d-u\t x-rci (c► t. l.Q 1�S a' f7? IL_Q
airy, Corsi- )Ch on l I ft. T4 S J
Facilit#Orsnerltow n• ft.
W r( V Facility 1DN(if applicable)
Physical Address,pot and Zip l ft• tt.
1.'�a(kiU)(1 IBC% _21.REMARKS AUG 1 ' 2024
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) C •
J3 t 5c • a`t-D L
•
' �4S 13 W .� --1_ a_0 ,
6.Is(are)the well(s): 't PHr eranent or ❑Temporary Si sane of Certified Well Contractor Date
.0y signing this form, I hereby cesyjfi•that the nell(s/was(were/rntrstrncted in accordance
7.Is this a repair to an existing well: DYes or No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fit mttkno+as:wellconsnrar/on rtiformarion infccrplain the nature of the copy of this record has been provided to the arllnnvler.
repair under#21 remarks section or on the hack of this ftn•m.
23.Site diagram or additional well details:
S. of constructed: You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages ifnecessary,
S.Numberb injection of wells oc nst ruct supply wells ONLY with the sour[construction,
submit one form, you can
f SUBMITTAL INSTUCTIONS
`
9.Total well depth below land surface: 1-•(- 24a For multiple wells list all depths ifdifferent(exam le-WOO'and 2C°3 �'l (ft) For All} construction to the Wells: Submit this firm within 30 days of completion of well/ following:
10.Static water level below top of casing: -1 0 (fL) Division of Water Quality,Information Processing Unit,
1Jlsmer lore!1s above casing,use + 1617 Mai(Service Center,Raleigh,NC 27699-1617
i n 11
11.Borehole diameter: t,a( S (In.) 24b.For lniectlon Wells: In addition to sending the form to the address in 24a
12.Well construction method: above, also submit a copy of this form within 30 days of completion of well
r c. t-Ct i"'-( constriction 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
13a.Yield(gpm) I 0Method of test: -I `,1 24c.For Water SRDDIV&ini!ction Wells: (n addition to sending the form to
I 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-) North Carolina Department of Environment and Natural Resources-Division of Water Quabry Revised Jan.2013

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