GW1--04954_Well Construction - GW1_20240816

56
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 rt. ft. -
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(It op neable)
W
FROM TO DIAMETER TCKNESS 5 MATERIAL
Clearwater Well Drilling Inc. 1 rt. --(C) ft. 1 S' in. I p',C
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. In.
List all applicable well construction permits(i.e.County,State.Variance,etc.)
ft. ft. In.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. It. in.
❑Agricultural 0Municipal/Public
❑Geothermal(Heating/Cooling Supply) _esidential Water Supply(single) ft. ft. in.
❑IndustriaVCornmercial ❑Residential Water Supply(shared) 1&GROUT
FROM TO /�MA�TERIIA��L� {- EMPLACEMENT n ETHOD&AMOUNT
❑LTiWate ( ft. an ft- ley I C'.C�t 1 t 11y . 1
Non-Water Supply Well:
ft. rt.❑Monitoring DRecovery
Injection Well: ft. ft.
['Aquifer Recharge ['Groundwater Remediation 19.SAND/GRAVEL PACK(If applicable)
°A Ulfef Storageand Recovery FROM TO MATERIAL EMPLACEMENT METHOD
qvery ['Salinity Ranier H ft.
❑Aquifer Test ❑Storrnwater Drainage —
D. ft
['Experimental Technology ['Subsidence Control
20.DRILLING LOG(attach additional sheets If necessary)
OGeothermal(Closed Loop) °Tracer FROM TO DESCRIPTION(color,hardness,soli/rock type,Grain size,etc.)
❑Geothermal(Heating/Cooling Return) ({°Other(explain under#21 Remarks) ( ft• -1 D ft- Silt t1/ ( �-.l,•v-A-
4.Date Well(s)Completed: pa / 1 Well ID# �(C ft. �' ( ft. (l�-i 1C.I 1rCC-.I t
Sa.Well Location:
.W� ft LC'a� Ci kA `X
voe- pet ft. ft.
F lity/Owner Name t 4�-t-1*Z' Facility 1D#(if applicable) ft_ i
hi of i rr Deer- t C;�.h m , t'&L-S 1-E-i I ft.
, ' ~ J ; ` t
Phyysiccal A City Zip N G 21.REMARKS 1 r}', 1 1. i
•
County Parcel Identification No.(PIN) It.I SDfl
f'5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2 .Certi ation:
(if well field,one fat/long is aciem)
c35 'n l • W u NI �a 33. 2-0 2- W �_______ S-i -a Li
Sig of Certified Well Contractor Date
6.Is(are)the well(s):)ermanent or OTemporary
By ' trig this form,I hereby certify that the well(s)was()sere)constnrcted in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ['Yes or Al: opy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information d lain the nature of the
repair under#21 remarks section or on the back 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 injection or non-water supply wells ONLY with the same construction,you can
submit one form. r-} SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: I (ft) 24a. For AB Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd,,different(example-3Qa 200'and 2@100') construction to the following:
LOD
10.Static water level below top of casing: (IL) Division of Water Quality,Information Processing Unit,
(Inviter level is above casing.use•'+•. ) 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter. 1 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
t� /� above, also submit a copy of this form within 30 days of completion of well
1 12.Well construction method: ot00--r- L 1 construction to the following:
(i.e.auger,rotary,cable,direct push,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) 3D Method of test: R 1 24c.For Water Supply&Injection Wells: 1n addition to sending the form to
�. 4 ,�l n {� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Oh i X Amount: I C) O ees completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

WadMew- CarfakrAkin
V /
owner r- New
I befeby Eatery that the above referenced wel waa grouted in appearance in
accordance with
ail CountyWe 1 rules
welt uric, Y IGUS ��
Ce iBcat0V; \ 3 - A DNateGro
Construed= Grout
Casing Depth: 0 _v
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