GW1-2021-06908_Well Construction - GW1_20210505

WELL CONSTRUCTION RECORD For Intemal Use ONLY:
This form cm be used-far single or ato#iple welts
¢ L Wen ContractorIoffirmW6n:
Ronald E:'K-eeter.Jr.. L4 WAT88ZOI�S t
FROM To I DrscRiprtoN
Wen Cor i�aarxane ten IL j
2960-A ' I
NC wellGorarectacCestifieatioallomber A0VfMCASING raafYfarsaweb OR1f91F�
FROM TO DIAMErrR THICttrtESS MATERIAL
Southeastem Pump&Well Service Inc. + p k-
CoaepaayNeme �-y ///��� I&ME'BCASMORTE7JCRtaVt' du'ed
+i a�,.G i( , FROM TO DL4M rMr 'FMCKNESS MATMUAL .
2.Well Comtnncflan Perm t#: 'a-A. Jl (I� R. fL IL
Lid aA'applicable,"M coorrtr wUmpamf(in Cawny,Slow,Va*wfa M)
it. ftw m.
3.WeO Use(check well use). 17.SCREW
Water Supply Well: FROM TO DIAMEM SLOT SOLE M4M I MAT RIAL
r"L❑Agricuhtanl it tL \!) �
QGeothamal(Hesting/Cooliag Supply) -i aardeatial Water Supply(Single) ft it to
OlndnelttiaVCommencial nReaidentia!Waal supply(shared) ltt t;RMT
FROM TO MATERIAL. METHOD&AMOUNT
Qhmi an fL IL
Non-Water Supply WcU:
fL fL
t3T�anitosiag C R-overp >ti m
C)Agaiferlkedtarge QCuamdwatwRemcdistion L�tSAlIDfGBAVELPACH
QAquifer Stomp-d Rroovc y Mofi y Bonier FROM I TO I MATEM" I EMnI.ACE dM METH D
R M ft, -T
C3AOifcrTat QSta nswaterDreinsge fL
ff:
OF_gma rimatta!Technology OSabsidamca Cont<o!
21'A DBII LINGI.Of` atfsei aidYkrsl sMests R
Mkotitermal(Clcsod Loop) QT=cw FROM TO DESCMTION Mr,=bwftsk Wfa*Me,Vvft shK art
OGcothamal a ' " Retarn 13l7lhea(explain undcr#21 Rrmarfa) IL fL
4.Dots Wdl(s)Camptstsd• { _ _ ft; �.
5.Will I.ocatiaa: fL ft- VVr! +4T
thefL ft.
Fauca7iry erne FaeihtyID#(ifapplieable)
fr w �,, n ei I;;
�Ad��� 2LEP21iAABti
M f r! ' 1,77 x S
Couluty Pascalidemifcalioaxa.(PIN)
Latitude,
5b,latitude,and Langiinde to deglWiliYl�.KL1IlNs er dedmst degrees: „ *"6 e c
(if well Sell as is 40M is sufficient) 21 Certlseatlon: [r�u t.�ss..t,0 it
• C'rSigaaW w cf Ccrbfiod WcU C*&sdw ! Date
6.Is(art)the we5(* Peae.aeot or OTemporary By rigs d rJor I herby orrr(!y loot the wcA(il w�(were)cartr6vcsrd rA oaaardmrar
,rich I3et NCdC 02C.0100 or 13.t NGtC 02C.02QOWeg Consa ctb*Standardr and rust a
7.L this a repair to an ezbdng welk QYes or a copy of Ao reaad has been p widrd to the wcU owner.
If rlatr tratspag Ilttont krawa well msatrsremoar fi¢Oranation and apTavr the naawr of den
repair ender#21 ramarb sechm arm dare back of thisfirm. . 23.Site diagram or additional well debit.
i You may use the book of this page to provide additional wen site detsils or well
8.Number of wets colnMnted: ` constmetien details. You map also atterlt additional pages if uccessary.
FormadNpk iafaeti m or wn waorsup*wellr ONLY with dare aaae taaarraaoa,you core
Serbian one,farm 24.Submittal Imtructions:
9 Total well depth bekm land surface: I (ft) 24a. Far An Wells Submit this form within 30 days of completion of well
FornmttipleweArlistapdepthfdfrrant(esmnplIr-3@200'and2@IW) Gonshu tiontothefollawh*
10.Settle water level bebw tap of easing: (tt) MUM of Ws tw Quat[t7 Ufortentlon Frvices ft Units
tfjwafrr level is above caste&an 1617 Mall Service Centers Raleigh.NC 27699-1617
11.Boeerhole dlameber. �,.(w 24b.Eor hdodkoWa91s: In addition to sending the form to the address in 24a
above,also'submit-a copy of this farm within 30 days of completion of well
12.Wedt cons&aetlon method: 'A11 construction to the followitiF
(ie.aeaget,rotary,i ablq afaxt pan%etc.) Division of WaterQuaMys UnatergnKmd Injection Contra!Pragn me,
13.FOR WATER SMPLY WELLS ONLY; 1636 Main Service Cl--}ear,Ralelgbs NC 2709-1436
13a.Ytdd{gpm) Metbod of text: 24e.For Water Cu_wk& 1 We& In additiaa to sending theform to
1 the addres(es)above, also submit one copy of this form within 30 days of
13b.Dtdnfecfion type:_„ A Arnnont: L aompetion of wa#i aousCuction W 9ta county health dgratluteat of the county
where consbucted.
Farm{3w-1 ScutIsCowlice Dqxrbund ofEaviromocutcadxattaa)Reaases-DivisianafWartaQu lily Revised lam 2013
M