GW1-2021-06907_Well Construction - GW1_20210505

WELL CONSTRUCTION RECORD For latemel Use ONLY
:
2'his-firm can be und.for single or multiple waits
Welt ContractarImformatlao:
• li WATEBZONn k
Ronald'E:1{eeter Jr.. FROM TO LDrsct�rtorr
i'Ne17Cob�adarxeme •> - �. �'
2960-A - M
NC well Connacu r Cetti6eationNumalm 1S OvMt OM* �� *ab ORLII�iEit
- 70 1 MATERIAL
Southeastern Pump &Well Service Inc. I Q!k_I
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C0Uq)w lr Name 16 VMM CAMM ORTDBIDIG
FROM TO I DtAMEIEIt I TMCIOCESSMATtmI,u.
2.well Canstrvedon Petmk tL
Lis!arl applicable weft aonstnwri n as(isr.Comry,Stair.Varim k%eta)
fL tL in,
3.wall Use(docitwell me): 17.SCR EP.N
Water Supply Well. FRaM 10 Dw4E[rlt SIM S= I TIDCIinE56 I MATMUL
oAgnicultural t7Mn ' blic k 11
OQcothamal(lieating/Cooling Supp1Y) Ataidential water Supply(single) it ft. to
abndustriallCommcrcial DResidential watt Supply(shared) ORODr
11 cn
FROM TO MATERIAL Etdp'I.ACFMENTMEIFIOD&AMOt7NT
Non-Water Supply well: IL IL
aManitoring oRtzovay fL m
OAquiisrReehsW IIGroondwaterRcmcdhation 11SANNGRAVELPACB
oAquifer Statage and Ra way Malinhy Barre[ FROM TO MATERIAL I EMPLACP1 MT METHOD
DAquiferTed oSta mwatatDminaw
DExperimental Technology IISubsidence Cantml ft tL It
DGcothamal(Closed Loop) Mincer FROM TOE DUcRIpnoNY(eabr—b—o—t-o-elmtow�m*tymffatnskoaLi
aGeothamel(Ii t Rctam) 00ther( lain the#21 Remarks) ft. &
tL IL
4.Ilene wdl(s)Completed:
We'll Lacadon. h, tL
t .S( D. tt. -
waitylOwnarName FecilityM#(ifepplicebk) (t fG $=tea sa•�? q
2221
ical�A\ �k1 �. 2LSEMARBs � s ! Sh
,,,' ,��, ,Il•�l• rryrn .nnn�}'1�, t.�i iii,
CMVAY PincelldentnfteanoaNO.(PIN)
� V�v
5b.Ladtetde and longitude ba dep,,,f, secouds or ded, degrees: 22.Cerdffcadow,
rNO
ifssell fwld,one tetltong is cuff cmat}
,I*..tm of C fiw well Caatrecaor !)
6.b(are)the weD(a): ermarsart or aTem porary gy,ems&&f-^1 hwwby-n*that rhe'vc5(s)Eras(rest)oaa+krCftd to a=wwi=w
with 114 NCAC 02C.0100 or ISd NCAC tVC.020#WeR Coxrbvcdan&mzf rds and that a
7.U this a repair to an existing well: DYes or o copy 4;f"reaurd has been p vvhhd to the well owner. '
if th:r isarepair,,fII arthaawn well rnrubvcafox ulformatbn axdesplairr the genes afthe
repab under#21 runaekrseak=or an the bast of thit)F6rm. 23.She diagram or sdddond well details:
You may use the back Of Ibis page to pmwide addifia and well site details or well
&Number arwells constrocted: canatmotion details. You may also attach additional pages if necessary.
Form driple Weettas or rsn►watrrs WI)O weHr ONLY With du sane eaesew4WOM YOU can
sabrx¢asrfona �}�} 24 Submittal Imtrocdoos:
9 Total well depth land below la amface: (-"``-' (ft.) 24s. For All wells: Submit this fam'within 30 days of completion of we11
For eedtipre went[at aDdepdesifdio-M(cwmgw--V2(V'"aard2®1W) eonatmcdonto the following:
lab Steals water level below top ereask er tip (M) DlvWom orwater t2uallw,Iurorm adon Pivc whe fink,
tfjwaterlewrl isabowr cartxg;aPu`�"+" 1617 Mall Serda Center,Raklgh,NC 276W1617
11.Borehole diameter. `-/� � � M•) 24b,For:n In addition to sending the farm to the address in 248
�� above,also'suhmit.a copy of this farm within 30 days of completion of well
I2.Wen casndraction mefhad: �S� conattuction to the following 4
(i e.in rotary,cab*&wt push,eta.) � Division of Water Quality,Undetwr uud Iujeed.Codtr al Program,
13.FOR WATER BUPPLX VYELIS ONLY; 1636 Man Sa ove Coder,RakWN NC 27694-1436
13a.Yield(gym) Method or tat: 24e.Fbr Wad'Smmk&E" l Wdia: in addition to sending the form to
the addmm(es)above, also submit one copy of this form within 30 days of
I3b.IlWnfeetfoa types Ana., 00mplation of well constrmtiao to the meanly health depsaftent of the county
where coushucta i
FMMGW--1 NmthCatolitmDepmtsmentofEumazaaa tandNanaalResmuces—DwisionofwawQualty RevisedIc.2013
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