GW1-2021-06896_Well Construction - GW1_20210505

WELL CONSTRUCTION RECQRDPer
'3� �L latemslUseONLY.
Tbis farm con be used.for single ormuNple wall+
1.Well Contractor In6nd un: f✓ l I
Ronald E: KEeter Jr.. / � " r 14.WAMZOIM P
FROM TO I DESCRIPTION
WeftCdiotradaNams '> - fL IL
2960-A n n
NC Well Comraetor Cerd&cation Number 110 IZ CA �ORL
nROM TO DIAMn rt8 TIitCKNE.tB MATERIAL
Sautheastem Pump 8t Well Service Inca
Cotnpaay Name i6 UOM CASIM 40MR 7Bt[VC;filectlewsed rloasd
2.Well Con str octloo Peetuft#t 4 0 _1 � FROMft. To FLDIAMTM Ii�clav�s MATESIAr.
List off applicable rpeff wvumueHanpnmitt(ts Cworry,State,Yari"M:tees
n n ;.
3.Well Use,(che&well rue): i7.SC3l�R
Water Supply Well: FROM T^O� DIAs�/' . SUn StZt; MCD-M MATERIAL
QAgniculbtra) QMo ''ipaUpubfic l n O n �� 1e (� C..
Moothermal(H�g/C�g Supply) IaResidmtial Wales Supply(single) ff. tt. In.
OZadustfiallCommetcial ORceidaitial Water Supply(shmtd) 18 GROUT
FROM TO MATfSR1Al. MUTMODAAMOUNT
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Nan-Water Sup*well:
IIMonitotfng ORecovety it. fit.
Injection Wen: n ft.
MquiferReoharge OCnvtandwaterRemediatital 19 sArmits'BAVELPACB
OAquifer Storage and Rcoovay IISa&oity Banier FROM TO�} MATERIAL ZMPLACft9HSNi MSfHOD
DAquifcrTeat OStamwattxDrainage ` n Zq n -
QExpe:imental Technology OSubsideuce Cotmal n !:*
2RDRUAMGLOG rA attdWonalstsesUff
QGeothamal(Clasod Loop) IITraccr FROM TO cvbr sdVtatt st des
IIGtotltamal Retum) OOthcr( lainuudcr#21Rcaisdcs) a t n Q
4.Date Wd](s)Completed: _
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S.Well Loeatf M: ft.n n
kon n �,
FacalaylOwnaNmne -��� FacilityIIJlf(ifepplicabb) °"'"°
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gas
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county Pawl I&WfrcatianNo.(pm) is! ,'c l l l =.vY t`t W ��i e; .art
'fib.Latliude cal Iasngilude{n da8realmfmrtalsecoWs or deefind degrees: 22.CetyiRcatlon: v V
(if wall field aml is sufficient)
N W - ., `" 1 .fit
�„/ -SVBture of CMbfiad Wall Caohachor Ddb
tit L(are)rise wei!(i} Of'v sauce cant or OTemporary i
BY xgmng*vfwn I hereby orn*tW the welf(sf was(ware}mannered in aavrdo nx
+rich 114 ArMW 02C.01W or 15.4 NCAC 02C.0200 Weft Coasev does Smndanb and 4W a
7.L"a repair to an esisfloa well_ OYes or o copy g/shtr record has ban pnvidrd to the will owner. '
If thtr fa a r+epocfiff outksown wtAconrnvcmfisa 6�armatbo arid espbsdr the nasrrs afths
repair corder 921►evnvkrreeaon or m the boat ofthisform 23.Sfte diagram or additional well detalh:
You may use the back of this page to provide additional well site details or well
&Number of wells constructed: ccaatactiou details. You may also attach additional pages if nccosary.
E'ormtddf r ngratfon or non waarsupisly wells ONLY wfth the mom come,% wa,you con
svbM#orrefonn. 24 Submittal
9 Total well depth beinw land surface: (iL) 24s. For An Wells: Submit this form within 36 days of compktion of well
For—Wlde weIIrUaoff depifts ifdj ftrant(-="pI-3@200'*qxd2(IW) COaShvc Lion to the IbIlowitiF
14L StaMc wader level below top of easing: �LJ (L) Divbfoo of Water Quality,Iulhrmaden hucesalpg U^
(jtverarr level tiabow caftan"+ 1617 Ma Serda Center;Ratetth,NC 2709-1617
i i.Boeehok diameter. _ (fn.) 24L For InircOms Wells: In addition to sending Ste form to the address in 24a
above, also submit a copy of this form'within 30 days of completion of wall
12.Wefl construction arethod: ' /� construction to the following:
(Le.sugm tot".cab*&rcotFah etc)
Dfvhfon of Water QaalHj,UadetSrormd Injection Conboi PrD=ram,
13.FOR WATERSOPPLY WELTS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
139."Yield(gpm) Method of test: 24c.Far Water &Geaiho osl Welh: ]a addition to sanding the foam to
the addreaa(a)above, also submit one copy of this form within 30 days of
13b:Dish'ecdon tRyper _1 Amount: ao
�Xqcompletion of eel. constructionconstructionto the aom�ty htattlt department of the countycountywhat consteted.
Form t3W I Nmth Csrohm DopmtvAtd of F=vu=nme w d Nstu W Resmasaa-Divoioaof Water Quality Revised lea.2013