GW1-2021-06886_Well Construction - GW1_20210505

LL CONSTRUCTION RECORD
- _ F-1'nte®1 Use ONLY: S
facet cis be wed-for single ormuttiple wells
1.Well Canhuctor Iafosmatidn:
Yt
ROnald E: KEeter Jr.. WATER ZONES
FROM TO DIXCRIPHON
wellcoturidarxame tt r-I ft.
296aA ft &
NC WeU Coftacta CerbfieaionNumber 1&OTTPER CASING orwmawc rd wed ORLA�
FROM 70 DIAMEM- TMCKNMrSB MATERIAL
Southeastem Pump&Well Service Inca O >tIto 0-k- - �.
CompaayName is.IPIIrMRCASIIdGORTtJ81NG elotad
� n FROM TO DIAMLIEW TAICKNFSS MATEUAL
.2.WellConstrwilonpevaitfls J {�\�, L R tor.
List oft apphimbb:well aorurmerfonpe/mie(ii.Co>Ary,Starr.Varioned%Oral
tt R m.
3.Well Use(cheek well men 1�SCREEN
Water Supply Well: FROM TO I DUMUER I BLOT SIZE I THIeKNEBa F MA—AT
t .
❑Agrictrltnral ❑MD ' ' blic 1 �- Ilicyn I ZIG JVVC
❑Geothe al(Heating/Cooling Supply) es�WdW Supply(single) ft. It id
m
❑brdustrial/Commereisl MteaideetW Water Supply(ahmed) 18 GRMT
FROM TO MATERIAL I EMPI.ACF1AMK fHOD&AMOUNT
Girrigation
Non-Water Supply Well:
❑!t!2ring Ocovery R h
Well'. tL tL
❑Agnif-Recharge DCmooadwaterRemediation IASANBIGRAVELPACK
❑ a FROM To MAWRiAL EMPI.Aeraaea METHOD
Aqafifer Storage and Recovery ❑setmrtyBsaic OAquiferTest ❑ lh Stormweterainege !
0Experimental Technology ❑Subsidence Control
M3QDRE[JMG1L,OG❑Geothermal(Cloeed Loop) Mincer RIPTION color senhust❑Geotheamal(H Retem) ❑Other( lamunder#21Remadnr)4.Hate wd1(a)Completed: ao2.WeU Locatba: L
R &
ecility/ownwName FecilityID#(ifepplacable) IL fL n s�
claQ qrn I l-t 9 A fL & fi
i v ...
utcalAddreM City.sad Zip 2L REMARKS
o-mde-n 14,
C-L-Ly Pa:eelIdemificatioallo.(PM r�faG^-I �iil�
SL Latitude and Iargitude in fllgae wolionteatseConds or dedmal degrees:
ifwell field,oneladiongissuf view) 22.Certification: (,jVVRSectioit
Ll �IIQ. l W
igffihae ofCedi6ea WeU eonbeeter
6.Is(are)the wefi(s): Pemaneat or ❑Tempo w7
By si8a+r+8 drirfovrth I hereby artily that the weIIm was(wench carsbrated br acivrdmar
with 1 U NCAC 02C.0100 or IM NCAC Q2C.0200 Wag Consa ucffan Sfmsderdr and that a
7.Is this a repair to an existing well: DYes or No copy cftW record har been providrdtofirweil owner.
If thin is a repay, W-out hmm wen coastrvC&aa v¢otmatioa cord esptaut the aatrve of the
repair wider s21 remarbseeNea or an the back ofthuform. 23.Site dlagm or additional well details:
You may use the back of this page to provide additional well site details or well
L Number of wells construded: construction details. You may also attach additional pages if neoasary.
For ndhpirbyeetimornon-wn&rz piywellrONLYwtthdwsagecoubugeon,youcan
submit one form, (� 24 Snbmtttal InthveHom:
9.Total well depth below land surface: �J (ft.) 24a.For AU Wells: Submit this;'form within 30 days completion of well
For rmdh'ple we/GJfrcall dep$a if d&-w(eeamg-3(d W'atd?(JW) coD rinwti a to the fbllowing:
10.Sbafle wate level below top efeasirg: (C) (g,) Dlvidon of Water QmNt7,.Information Ptoeea ft Usk,
f/woar level is about cas &as 1617 Mall Service Center,Rsl�h,NC 27699-1617
11.Borehole diameter. (In.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well eemfraetion method: l i>�JL above, also submit.a copy of this form within 30 days of completion of well
consttadion to the following:
(Le augur mfary.cab*&-t godly etc.) _
Division ofwater Qmdlty,Uod-w—W Injection Conroo)PrWam,
13.FOR WATER SUPPLY WELTS ONLY: 1636 Mall Seratas Cerdw,RAelgh,NC 27699-106
13a.Yield(gpm) Method of test: 24e.For Water Suwk&Goo ftn W Well.: In addition to..ding the faro tD
the adrheas(es)above; also anbmitlone copy of this form within 30 days of
�
13L Disinfection type: A �; completion of well contrndion to the county health department of the county
whore constructed.
Foal GW-1 NcuthCarohm Depmtrmrd of Eavuonment end Natural Raaaas-Division of WaterQ4reldy Revised Sam 2013
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