GW1-2021-06911_Well Construction - GW1_20210505

WELL CONSTRUCTION RECORD !
Thi►farm cm W.be= -for single or.multiple well: Far huemal Use ONLY: f
-4—Well Coaftdor IDfvrerafloD:
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FROM TO DESCRIPTION
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NC Well Couftxttar CatificzdonNumber M OTITER CASH ssr;lti erred weL ORlzm
Southeastern Pump &Well Service Inc. FROM OR- 1To t�_ D I, ' �`KMM MATERIAL
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2.Well Construction Permit#r & R !s
List all applicable well oaamacrion pamttr(it.Co:eay,Smar.Yarianm eta)
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3.Wen Use(checkwell me). 17.SCREEN
Water Supply Well: FROM TO DIAMEIM SLOTS[ZE TWCICYESS MATERW,
❑Agriculhual ipaVPublic (�
❑Geothermal(Heating(Coolin8 Supply) aidantial water Sppply(single) fL is
❑lndustriallCommemiai ❑Resideatiai wales Supply(shored) "LGRODT
FROM TO MATERIAL EMfq ACEMKNT METHOD&AMOUNT
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Noo-water supply Well:
❑Maniioting ❑Rcoovery
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Injection Well: tt R.
OAquif_Reaharge ❑Gro ndwatwReatediation to SANWGBAYELPACS
❑Agntf-StorageandRecovay ❑SalmityBanier FROM 70 MATERIAL EMPLACII4lEN/I METHOD
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❑ ft.
AgaiferTesi ❑StormwatwDreinage
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❑Experimental Technology ❑Subsidence Control
❑Goethermal(ClosedLoop) ❑Tracer 24DRnLWGLOG sWetiaddWk=d sstrr
FROM TO DESCRIPTION-br, saWtatt41M vow sk aft.
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4.Date Wsn(s)Completed: �P V
S.Well Location: -VtR fL
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r FscH41OwnwNezne r Facility IIJJI if fncable w
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Physical Address.City.aril . 2L REHABS®
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Canty ParcelldentifieatianNo.qw) r a. q� 1 I ,vrr S-3i L?Vllt � Y.r� �o ll
5b.Latitude and Iangitude in degses/mh infawands or decimal degrees: V l. ,. r
_(ifwoll field,am l yb%is sufficient) 22.CertMeatlon:
3 r C6 W �✓y--
Wsbae of Cat1W Well canbecmr
6.Is(are)the weil(s): ...t or ❑Te7vo-,-�
By rib ft�fao'+fR 1 hereby cvn*that:tht wev(d was(wen)cau&uded at amordmrcr
with 15d NCdC 02C.0100 or 15A NCAC 62C.0200 Well Conshuceian Staadards and tint a
7.Is this a repair to an existing wen: ❑Yes cv"O tAkr need has been povidedto the well awnr. '
Ifdir is arepab,ftQ aattrrasm wenwnrtrvcSoa 6farmaYba and ezplade dx reserve ofthe
repair sailer#21 remmlasrchm arm she boat of Nmfarrp. 23.Site diagram or addl-' well detals:
You may use the back of 9»a page to provide additional well site details or well
8.Number of wells constructed: oenettuotion detk&. You may also aNarlt additional pages if necessary.
FormidbtskuYedimorronwatrAT*wel&0 wdhthamreeartbrNfas.yosamf
svbmitoneforM 24.Submittal ImhtrYom:
9.Total well depth below land surface: CL♦J (ft,) 24a. For AO Welly, Submit this form within 30 days of completion of well
Far n-Nple we&1i t-H depdrs rf did'-w(esm ipl-3@200'and 2®1p0) couatrudion to the following:
10.Ststie water level below top of mi g: �n (fL) Division of Water Qualky luformation Rvicesahe Unit,
{jtrote.level it above earft use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For IntectioD welt: ID addition to sending the tam to the address in 24a
LL— above,also'submit a copy of this farm within 30 days of completion of well
12.Well construction metlnod: ny0 t conetraction.to the fnllawring:
(i.e.M*-.totm9.-W direct Pak ctr)
Dlvislon of Water Quality,U-kvground 1u*don Central Prog a k
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mall So vke Cen'hr,Raleigh.NC 2769946M
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13a.Yield wan)) Method of teat: 24c.For Water Su &Gm i Wens: m add�ea to sending the form to
V' the s(es)above, also submit one copy of this form within 30 days of
13L Disinfection OW. 4-1
� �� Annmrt:�G 1 i'� completion of well oaostroctim to the county health department of the county
where conshacted.
Fotm GW-1 North Carolim De wUneut ofFavixonment and Nstural Resoraees—Division of Water Quality Revised Jan 2013
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