GW1-2021-06897_Well Construction - GW1_20210505

WELL CONSTRUCTION RECORD For hete®I Use ONLY:
This farm can be used•for single or.tnuhiple wells
ontrodor Informatla:
14.WAT-ERZOMM
Ronald E: Kseter:Jr.. FRnM TO DEacRinOR
WellCouti�etaName - tut, lavL
2960-A ff. rL �
NC Well Coubwtor Ca fication Number IS OurER CAMM awsealfFssid'"M ORLDiP.R
FROM TO I DIAMETER-• T1OC7LrIE45M�j MATERIAL
Southeastem Pump&Well Service Inca o- _I , 1 16
companyNema _ 16CAaM ORT1l1ti11K' ddttd
FROM TO I DIAMETER" TMCKNM MATMAi,
2.WeB Con dr utdon Permit tt
Lid all appliovb&ve0 aoravacsionpnrnia(is.C-Day Sate.Yarima+R C-)
ft. I & is
3.well Use(ebeckwell use). 17.crRxwK
Water Supply Well: FROM TO DIAME[FJt sLor St21: TMCENE85 MATERIAL
DAgrioDllDtad j11 le L L( t
OGoothe mal(Heating/Cooling Supply) X�-aatt Supply(single) ff' In.
OTndusttial/Commerciel ORceidential Water Supply(shared) �ODT
FROM TO MAIERLAL METHOD&AMOUNT
Ckrigation
Non-Water Supply Well: 0 R `k Cr Jo K
OMonitofing Mccovery
Injection W . fr M
0AgoifcReeharge 0GwundwaterRemcdiation M
RAVFtPACB
DAquiferStorage and Recovery OSa&nityBseier TO MATERIAL EMPLACEMENTMUHOD
DAgniferTcet OStotmwaterDrainage I201 1L
DFxperimental Technology OSubaidenx Contml
20.DBD:LINGLAM sRtsehaddooftfilshaftif
OGeotitamal(Cloud Poop) OTiaeer FROM TO DESCR>PrION fmbr sotvevetrOT4 sha etc
DGeothamal(HestingAcocting Rat=) DOther( lain under#21 Romades) 0 R O tr. � (�
4.Date Wed()Completed:
1L
5. 11 location: f 1 !ti h. `
Facility/ Neme 1 Fete'' 1M(,fepplieablo)
ft
h yualAddess.aty.
2L BEh(AZHol ] r Oa-Mt
CounLy Panel IdemfieadmNo.(PIN)
5L Latitude and LAngitude in der wolmhostalseeoads or den!'mat d '1 n{.c,S e�.I
(dwellfiel/^d CDC
hvkvgnrr�eront) _ �- 22.Ce4M i' il Aa the wei 0 vas(were!coat {p I
^e rgnsbav of catifiod Well Conbador te Da
fi.Is(are)the weR(s):Jae or OTemporao7 By*xft&irf-m I hereby arty& brrctcd ie aavrdaace
with 15A AR:lC=.01W or M NCAC MC.0200 WtOConrtrrre8on Standardr and dud a
7.In this a repair to an esisdrg welk DYm or o ropy g(thir record tear been
Ifthir is a repay,fit asrtrbtova yell maa6rrcCoa irrforraatioa artde=plairr stet agave of the Pad m the vrQ owner.
repair corder d21 remarbsechan or at the bast:4lthisform. 23.Site diagram or addonal weD dots ib:
i You may use the back of this page to provide additional well site details or well
&Number ofwells constructed: l conshation details. You may also snub additional pages if necessary.
Formalffplr byeedon or son vatoraopply velk ONLY v3h Bre arse eanbitadom you Cox
svhmitomfonrr. ` 24.Submittal Imtruedom:
9.Total well depth below land surfaee: 1 (tit) 24o. For AR Wdb Submit this form within 30 days of completion of well
For mrMp&—Arlidaffdepdw fd(Qerew(temrtple-3@2000'ard2@IW) eongWCtimto the followh*
10.Shade water level below top of esshg: L9 (n) Division of Water Qualityl-hWormatiou Processing Unk,
(f water level t above carhrg,sae^+^ 1617 M8H Service Center,RaleFgh,NC 27699-1617
11.Borehole diameter. (ta) 241L For Int doo Wens: In addition to sending the form to the addmas in 24a
�+► r above, also'submrt.a copy of this!form within 30 days of completion of well
12.Well eomtr oction method:T 1 to�1 ` _L I eonsunction to the following:
(Le.argon votary,babK diteet push etc.) �
Dtvtdon of water QusJ*,Undes�svuud Injection Contal Progro1%
13.FOR WATER SUPPLY WELLS ONLY: 1636 Ma8 Servke C"atber,RdekA NC 276W1636
13a.Yield(gpm) Method of teat: 24c.Far Water amok& W0. ht addition to sending the f rm to
the addteas(ea)above, also submit one copy of this form within 30 days of
13b.Didnfedlon types Amount. CLQcompletion of well eeushuctieo to the county health departelmt of the county
What constructed.
f f
Four GW-1 Ncdh Ca uhm Deparbmmt of Eavirommew md Nassau Raoumn—Divisioaof Water Quality Revised lea 2013
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