GW1--06332_Well Construction - GW1_20241022

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells j
1.Well Contractor Information:
Rex Meadows IA.WATER zor m9 •
FROM TO DESCRIPTION I .
Well Contractor Mune it ft. II
2113-A n• a. I
NC Well Contractor Certification Number (S:OUTERCASING(far multt.eaeed wells)OR LINER(If op table)
PROM TO DIAMETER THICKNESS MAIlIBIAL
Clearwater Well Drilling Inc. / e• 75 1 jp%P; In. , I /)fry .
Company Name 16.INNER CASING OR TUBING(aeethermal closed-loop) /" •
FnOM TO DIAMETER THICKNESS MATERIAL '.-
2.Well Construction Permit#: R. it In. I
List all applicable well constraetfon permits(i.e.Connry,State;Variance,etc.) -
f+, R. In,
3.Well Use(cheek well use): 17.SCREEN I
Water Suppiy Well: DROM TO DIAMETER SLOT SIZE ' THICKNESS MATERIAL
R. R. .In,
ElAgricultural OMunicipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) n' ft' 1°' I
❑industrial/Commercial :Residential Water Supply(shared) r: OM Oirr To MATERIAL,,/ EMPLACEMENT METHOD&AMOUNT
❑Irrigation % it /AV ft. 1-d�J7f'/1P 4f
Non-Water Supply Well: it. ft. I❑Monitoring ORecovery
injection Well: R. It. - I
❑Aquifer Recharge CiCroundwater Remediation .119.SAND/GRAVEL PACK(if applicable)
OAquifer Storage and Recovery ❑Salinity Barrier PROM TO MATERIAL I EMPLACEMENT METHOD
ft. ft-
❑Aquifer Test OStormwater Drainage
ft, II.
ClEytperimental Technology OSubsidcnce Control 20.DRILLING LOG(attach addllonel abseil If nccatsary)
°Geothermal(Closed Loop) C]Tracer ,FROM To DESCRIPTION(color,hardness,soilMek type,grain lire,ete.)
❑Geothermal(Heating/CoolinggtRetturn) clOther(explain under#21 Remarks) / ft' H• fJ/jo 7 kIJ/4
4,Date Wells)Completed: N /3 T[Well ID# �� B. 71
l• ara I
Sa.Well Loco c.)V 7 n. '2b n. e /ce I
Pacillty/rw erName LotI/ Facility 1D#(ifapplicable) }�',_ ,�,•, ,'•, ' •
C_ )i/ (/f`E'.41 6Drr vp, Heirs tf// �e tl
. . ft. 0(11 .4 % [U14
Physical Ad(iresa,City,and Zip t
21.REMARKS I
/- (//c ') ,Ir.f,n ,. . r= _ ..-:�•WA:t
County Parcel Identification No.(PIN) ( ° "° ""
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certl C on:
(if well field,one Ica/long is sufficient) ��
5 50 N g0 3e ���� w 9-It,
Signah ea-oTCcnified Well Contractor ' I Date
6.is(are)the Welk* ,,t��((Permanent or ❑Temporary
j°� By signing this faun,I hereby ea*that the well(s)was(were)tmnstrttcted in accordmtrey_
with iSA NCAC 02C.0100 or ISA NCAC.02C.0200 Weil Construction Standards and Mat a;=•
7.is this a repair to ma existing well: RYes or IDIVo copy aphis record has been provided to the well owner.
!Phis is a
repair,fill out known well construction 0 favnatlon curd explain the nature ultra
repair under#21'marks section or on the bark of this form. 23.Site diagram or additional well details:
You may use the hack of this page to provide additional well site details or well
S.Number of wells constructed: construction details, You may also attach additional pages if necessary.
For multiple infection or non-water supply wells ONLY with the same Construction,you can i
submit one form, SUBMITTAL INSTUCTIONS •
a
9.Total well depth below land surface: I. `r (ft) 24a.for Ail Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lfdff/brent(example-3(g200'and 2®100) construction to the following: •
10.StatIc water level below top of casing: &D (ft.) Division of Water Quality,Information Processing Unit,
If water level is above easing,use"+" 1617 Mall Service Center,Halals,NC 27699-1617
II.Borehole diameter: LP /�S (in.) 2Ab.Per Infection Wells: In addition to sending the form to the address in 24a
1 above,also submit a copy of this form within 30 days of completion of well
12.Well construction method: /tD!OYU construction to the following: I
(i.e.auger,rotary,cable,direct push,etc.) .I '
• Division of Water Quality,Underground njection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gptn) 6 Method of test: ,/, 24e.For Water Sui niv&Ill eaion'Welig: En>o dition to sending the form to
/�.��1 the address(es)above, also submit one copy this form within 31)days of
13b.Disinfection type:LA ion At- Amount: (P DV/7C S completion of well construction to the county health department of the county
where constructed.
Form OW-i North Carolina Department of Environment and Natural Resources-Division of Water Qpality - • Revised Jan.2013

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ownem edi ddle Newiffell: V/
1"011/1tId1resm JIqvieo Dr.
Pena; HAPTA
I hetthy earticyf hat the above ritforenaxt well was grouted in • In c rdanwh
Cotmty Weil mks.
wen Deter____12( Nwdoof
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Cadikate#: <9//3 Oft GOMM& 9 --43 c •
construed= Grout "
Total Depth: gar TYPet ',A
Cathg Type: pvc Iltidaxess
Cluing paper: 75 Nal: 4
Diametert ( 7
WathriThicic
raltre-sh _
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