GW1--04950_Well Construction - GW1_20240816

WELL CONSTRUCTION RECORD _
This form can be used for single or multiple wells For Internal Use ONLY:
I.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 IS.OUTER CASING(for multi-cased wells)OR LINER(if ap Ileable)
FROM
Clearwater Well Drilling Inc. FROM TO ft. 1(.1.•
DIA,1tETEP ) THICKNESS MATERIAL
I
� 7icZ �. I(
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) PVC
2,Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
List all applicable well construction permits p.e.County,Stale,Variance,etc.)
ft. ft, in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft. ft. in.~
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft' ft In.
❑Industrial/Commercial ❑Residential Water Supply(shared) IB•GROUT
❑Irrigation FROM TO MATERIAL EAIPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: i ft• L ft.
❑Monitoring ❑Recovery ft ft.
InjectionWell: ft. ft.
ClAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(Ifapplicable)
Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATER[eL
EMPLACEMENT METHOD
D❑Aquifer Test ft_ ft.
❑Stonnwater Drainage _
❑Experimental Technology OSubsidence Control ft ft.
20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) OTracer
FROM TO DESCRIPTION(cobr,bantam,sot Vend:qpe,groin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft• '71 ft.
n /SCCj-mac .t-�r-t-
4,Date Well(s)Completed: If,I (a�y� Welle 11)# 1 t •�� ft. �j�,(�_l ft. t,,cLir- k... •�
5_ Well Location: -3.' i 4 O (-4 C`1-t 1 Tli K '-- 3t..c rt. '5L6' ft. ll/`11rCa_3I �L
I IYI Mr,(c e *'Y rt. ft.
4� L,r�- (l t ,
ft. ft.
FacilityiOwner Name^ �t' C'�� r Facility 1D#(if applicable)
lid 15 1_' A
\ortin Act-e ft, R.}r
Pls cal Address,City,and Zip ft. ft. / ! ..i•
`'��1� 1,��.-n 21.REMARKS AUf j `• 2U?
County ! 11
Parcel Identification No.(PiN) /
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: sGa;
(if well field,one Iattlong is sufficient)
2Z. er Ica60n:
W = .-- a-a y
Signature of Certified Well Contractor Date
6.Is(are)the wel►(s): ( Permanent or ❑Temporary
\ By signing this form.1 hereby certifi that the ue(lt's)it (were/constructed in accordance
with 1 SA NCAC U_'C.0100 or iSA NCAC 02C.U200 Well Conslrrrctinn Standards and that a
7.Is this a repair to an existing well: ❑Yes oro
If this is-a repair,fill out known well construction information at cl1 explain the nature of the copy("Phis record has been provided to the yell owner
repair under#21 remarks section or on the hack of this firm. 23.Site diagram or additional well details:
You may use the back of this page :o 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-writer supply Wells ONLY with the same construction,you can
submit WIC hsrm. SUBMITTAL INSTUCTiONS
9.Total well depth below land surface: 0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@;200'and 2@/0o) construction to the following:
LCJ V 10.Static water level below top of casing:
(ft.) Division of Water Quality,Information Processing Unit,
//•water kw/is above casing,we"+'I
V•� 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: I l�
(in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
�,�( above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ( O t -1 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) Method of test: �(�
/ i 24c.For Water Supply&Injection Wells: In addition to sending the form to
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-I North Carolina Department of Environment and Natural Resources-.Division of Water Quality
Revised Jan.2013

w Mew Sida6411rmot CMrilfi
0mM_ :C1Z
AftfteraulLuiorlirl AcresRapdr,
rbervby walk thattbe above referiszed weR weep groutedin,amen:i ice with
all aim roles.
��( me_adotADJwren _ ....--..�.-.,
fir, oft-3-A Diroaroutat
Carman: c ,t
Ibtal r th yO IANK
Drive Nhot
Mit