GW1-2021-06904_Well Construction - GW1_20210505

WELL CONSTRUCTION RECORD For latemal Use ONLY: i
This farm can be used•for single or multiple wells `
I.well Contractor 1n&r=Td6n:
ONES I
Ron FR TO
DM TO
ald'E:Xeeter Jr.. .wATF1i
FR DFSCRIP170N
we$Cobtaetarwame a. n'
2960-A tti IL I ,
NC Well Contactor CertificationNumber FROM
OU1ZR CASITIG asalfl+�Md web ORTZgM
FROM TO D1AMbTER Tld1CIiMEMM MATERIAL
Southeastern Pump& /Well Service Inc. Q SS /�� +� 90._. .. v
Company Name J FROM it t A�NNGORT111iIIV1; cidCM
FROM TO DIMlZTF.R' TffiCIQVF9S MAT1DtIAL '
2.well Construction Peewit#: tt 136
List aII applicable well comoucrAm perm s,(is.Coaery,smite,Vari=4 etch
ft. R i..
3.Well Use(check well me). 17 Sl31EEN
Water Supply Well: FROM
TO DL1bECM SLOT SIZE THICENESS Mw
OAgriculttlral paVPatrtic �m tt /�t�
OGcothamal(Heating/Cooling Supply) ideatiel water Supply(single) ft. tt: rd
Olnduutrial/Commercial CQtexidentiel water Supply(.hated) OMUT
FROM TO MATERIAL EMPLACEMENThMHOD&AMOUNT
❑ etim R fL
Non-water supply well. rL
❑Monitoring (]Recovery r w r�eJ
Injection We": m M
OAquiferRedwW OGruondwderRanodiation 19.SANDIGRAVELPACH ff
❑Agmf r&orageaodR.vey ❑Salinity Barrier ;!I
To li MATERIAL MACOMMTKUMOD
ti d
OAgniferTat OStuanvAderMainage
ft. IL
OEVerimeatal Technology OSubsidc=Control
20.DHII3.IIe1GLAM atlriaddWsaalsintsY
OGeothermal(Closed Loop) ❑Tracer FROM To DEWRnMON toDkr.hadam seurraft rim mrsta sms,eta
MvA rmal tH Return) OOlhor lain tinder#21 Rtmsrlm) ft
fL IL
4.Date well(.)Completed:
L Will Location:
�r�_ 1
Z- CAB
acility/OwnerN e e FeeiliWM#(ifsppticable) n n J�
Pbysical Ad&eas.City,and 2L BEMAHBS 5 aw
County Psa:elldemfseationxo.(PIN) M Ay A i) 2021
5b.latitude and Longitude in a/mi11131e/.econds or dedmd degeea:
(if Well fw1d,one let/longinsrfficiem) / 22.CertiAe 9iivil+;3tL91Processin(,J. U1111
3cl N ;,CP= ��� w i�� r3
rgmbae of Ge:tiSed Well Caotrectoe Date
6.Ia(are)the weli(s): OPermaneut or OTeijorary
BY signing thirfarsR!hereby«n*Me the weft was fwerel casstucted in amordmwro
with 114 MAC 02C.01W or 15A MCAC 02C.0200 Weff CombwcSon Stmdardr and that a
7.Is this a repair to an eidstins wet h 745 or ONO copy of thlr record has been provi&d to the well owner.
If thb it a repair,fiR oo known weII com&ucNon information and esplabt the aamm of the
repair under#21 remarkrseen=or on the boat of thirfo"M 23.Site diagram or additiooai well details:
You may use the back of this page to provide additional well site details or well
L Number of wells constructed: / caasttuotion details. You may also attach additional pages if necessary.
Formathple iafeetios or nwr wan#rAT*weMS oALywith the sane eesabradom you can
submd one farm. 24 Submittal Inftroetionc
9.Total well depth below land stnface: 24a. For All Wdls: Submit this form within 30 days of completion of well
For multiple wear lip aII depda if dtfferero(ermaple-3@.200'ard2@1W) eonsbuction to the following:
10.Static water level bellow top of ewinr: M) Division of Water Quallty,Loformation Psvicesristg Un%
if water level is above caring rue't^ 1617 Mall Service Center,Raleigh,NC 27699-1617
7
i 1.Borehole diameter. (in.) 24b.For LaiedtM We1B: In addition to sending We form to the address in 24e
above, atso'submit.a copy of this form within 30 days of completion of well
12.Well construction method: / " O coastmction to the&ll,,ijr ;
(Le.auger.rotary,oabK d'sect push,etc.)
Division Of Water Q.*,Underground Loiection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 276"-1636
13a.Yield(Um) Method of taut: Y 24c.For Water Stir &Cgothermal Welk: In addition to se ndmg the farm to
the addreas(es)above, also submit one copy of this form witbm 30 days of
�j&44 completion of weA oaostrod oa
ica to the county health department of the mty
136.Disinfection ' Amotmt: where caastmcted
FormGW-1 NosthCerolinaDepamnemofiinv=tmeut and Natural Resources—Div maofWaterQality' Reveredtan.2013
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