GW1--05770_Well Construction - GW1_20240926

WELL CONSTRUCTION RECORD Ribeef®I use ONLY:
This form can be used for single or multiple wells
I
1.Well Contractor lafOrmation: =
:
timlia� To R
Rex Meadows ItR'lON
ft. A.
Well Connector Name _
2113-A n.
Is. iCAStticr(fartull �tiultdtwellU OR1N1tess uv )
t
NC Weil Contractor Certification Number at TO s AMttTa1t Nrsa aiACERIAL
Clearwater Well Drilling Inc. / R. 1/ ft. 6275; in. rri?
}Limn** ray, �g�is oettsrea t gg'
Company Name FROM fMro =t DUMIrTplt lrtCttN:4S rylA7ttR1AL
2.Well Construction Permit#: ,)Da ' — w��400 _ n. 1...
List all applicable well construction permits(Le County,State.Variance,etc.) R. *, hl.
3.Well Use(check well use): 17.5C[iEM.
S
Water Supply Well: rt.
To gAttTtht f CAT milMAT�aIAL
R. ft. in.
❑Agricriltural C]Municipal/Public _ — •
ft n. in.
°Geothermal(Heating/Cooling Supply) idential Water Supply(single) _
©Residential Water Supply(shared)
OlndustrisUCbmmercial 1-1$.- Q1TT, i'.�' L
t
CRpM. 1�i' T�aTAL ttM1M A4CM NT!Karma AMOU T�
El Irrigation / R' 070 =Coin(0f fluff In'
Non-Water Supply Well: R. ft.
17Monitoring °Recovery 0, rt.
Infection Well:
°Aquifer Recharge DGoundwater Remediation 19.SAND/GRAVEL PAtif,Pldl�d '
FROM
TO Ai11TBRIAf, aMPtACEMPNt MtrTtiOD
DAquifer Storage and Recovery °Salinity Barrier (t, ft.
❑AquiferTeat oSttmnwater Drainage ft. ft. — -
°Bxperimental Technology DStiabsidence Control `10,01014,kRG LOG . Ithlitlae4 r)plts,itn ;; :
°Geothermal(Closed Loop) °Tracer 1,FROM TO OESCIU ONNy(Mir,t diesLA.tAWKI1biroeeriesize,ere.?
(Heating/Cooling Return" ClOther(explain under#21 Remarks)f / R' / fi'� (mot pYer-/-
OGeothermalQ �c/ (7(� rt. h IL r
4.Date Well(s)Completed:U 7 a/VI/N1 tDq q( rt. 7 ft, l
5a.Well Location: Q 7 /as IL // i
Z I ma kind i--i ' ft. L R.
Facility/Owner Name Facility 1D#(if applicable) r • fL rt
/l Whiff ?d Weeitr_o/l /VC it. it." 2024
Ph 21
i Address,City,and Zip / U.REilitlRI h ,' '-
i./.rYT DIY)h ,:ti-.�v�
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degreeslminuteslseconds or decimal degrees: 22.Certiflcati
(if well fii�el��d
,one lat/long is su ficient) /
Signature fried Well tor— Date
6.Is(are)the we l(s): ermane nt or °Temporary
By signing the form 7 hereby certifr that the ne l(s)ems(were)constructed to accordance
with iSA NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair M an existing well: DYes or Yo copy of this record inn been provided to the well owner.
If AO iso repair.fll out known well construction information and plain the nature of the
repair under#21 remarks section or en the back of this farm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or Well
S.Number of wells constructed: construction details. You may else attach additional pages if necessary.
For multiple injection or non-wafer supply wells ONLY with the same construction,you can
submit one form. / SUBMITTAL INSTUCTiONS
9.Total well depth below land surface: /'5 (IL) 24a. For Ail Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(a1.200'and 12(a�100') construction to the following:
10.Static water level below top of casing: (�61 (ft.) Division of Water Quality,information Protesting Unit,
IJ water level Lt above casing,use"+•• / 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (..C2/f 5 (In.) 24b.For Injection Wells: In addition to send ng.the Ram to the address in 24a
1�y above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: I of rV construction to the following:
(i.e.anger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) / Method of test•. / C/ 24c.For Water Sunoiv&1piectlp,j,Wells; Ip 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(JW-1 North Carolina Dep
artment Environment anti Natwtl Resources-Division of Water Quality '
Revised Jan.2013

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Wen Wier _
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Cash*Deph: Y../ ----.-. -.___.- ..
Diainder: ( 7 %I
Height—
Drtve
GPM; 15