GW1--05812_Well Construction - GW1_20240926

WELL CONSTRUCTION RECORD -
This form can be used for single or multiple wells For interred Use ONLY:
1.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 15.OUTER�CASING(for multi-cased wells)OR LINER(if ap Ilcable)
FROM DIAMETER THICKNESS I MATERIAL
Clearwater Well Drilling Inc. it. ft. lX \,� in. ^�,C
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop) ' )
�G,- /) 7 /� FROM TO DIAMETER THICKNESS 11ATERiAL
2.Well Construction Permit#. g - UU e. J p( it. ft. tQ
list all applicable well construction permits(t.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
OAgricultural ❑MunicipaUPublic ft. ft. in.
t7Geothemial(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
❑Irrigation FROM TO MATERIAL EMPLACEMENT M THOD de AMOUNT
Non-Water Supply Well: ft ft. L C.
2I�1 i1 /�i
❑Monitoring ❑Recovery ft ft.
� l,� l ►
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation ' 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage _
❑Experimental Technolo ft• ft, -
gY ❑Subsidence Control
20.DRILLING LOG(attach additional sheets If necessary)
❑Geothermal(Closed Loop) El-Tracer -
FROM TO DESCRIPTION color hardae solUrock rape,groin size.etc.)
OGeothermal(Heating/Cooling Return) 'y/ ❑Other(explain under#21 Remarks) �] I it• CC IS p• 1.v(1 ('j�� �'
4.Date Well(s)Corn lete`d,p( [�� t Well iD# "'5 ft. 1 l' ft. I rote(k,
5a.Well Location: 1.�-(u ('j�71 I �L�S+• (1 ft' �{ ft. �) Q.
t 1 Sift. ,I fL VVV1tI y-% uX
lali h O ,i U1 ft. `Y �it.
Facitity;Owner Name Facility ID#(it-applicable)
\(4 3 ca OSSUI) 12dCC e, . QGI ft. ft.
� ft. ft.
Physical Address,City,and Zip L'�c CJ J '� ,w k ) 21.REMARKS T P 2 0 ?on
�Q KS tJ
County Parcel Identification No,(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: D'trC:13t"'
(if well field,one lat/long is sufficient) 4) ( ' 2 .Certi cation:
Sign Certified Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary
Br signing this-Juno,1 hereby certi&that the wr//(s)uuu(were)constructed in accordance
with 15.4 NC.4C 02C.0100 or 15.4 NCAC 0.?C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0';Vo coPy of this record has been provided to the well owner.
If this is a repair,fill out known swell cortstrvctiorr it formation ant explain the native of the
repair under#21 remarks section or on the hack 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 roach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the snare construction,you can
submit one farm. SUBMITTAL INSTUCTiONS
9.Total well depth below land surface: "1 L-VS (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(eramplc-41,200'rrd 2(ar100') construction to the following:
10.Static water level below top of casing: t Op (ft,) Division of Water Quality,Information Processing Unit,
//liter level is above casing,use-4-t . 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: lD (in.) 24b. For Injection 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: 1 V'03 �._t construction to the following:
(i.e.auger.rotary,cable,direct push,etc.) t
Division of Water Quality,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) 1 Method of test: \cl 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
completion of well construction to the county health department of the county
13b.Disinfection type: Amount:
where constructed.
Forte(1W-1 North Carolina Department of Environment and Natural Resources--Division of Water Quality y Revised Jan.2013