GW1-2021-00193_Well Construction - GW1_20210505

WELL CONSTRUCTION RECORD For lateral Use ONLY:
Thu form can be used.for single or.muttiple welt
1.Well ContractorInfottnwon:
Ronald E: Keeter Jr.. U WATF.RZONIIR
FROM TO DESCRIPTION
We7lContrsctaNerm >� `a y i. ; tL R
2960-A ' ` R R
NC Well Cofactor Certification Number X 2�21 iS OUTER CA ankt ea.d web 1LL FROM TOG DIAER Rffi MATFRIAI.
Southeastem Pump &Well Service Inc. ,,...tt�r�►rtr� + r�_ ;b,.
CompeayName Iil.�i►"_i, „ �E��.on 16IIVNERCA.4ING47BTUSIIVf' da.d
FROM TO DIAMETER" TMCK['M MATF8IAL
2.Well Construction Permit#: R R tier
List aQ applicable well construction perrnfu(ts.CowV,Same,Yarionce,era)
R R ia.
3.Well Use(cheek well met 17.SCREEN
Water Supply Well: FROM TO DL M M SLOTS= I TMCXNM
❑Agricultural ❑MnnicipaMblic LAOIL R , l°
OGeothamal(Heating/Cooling Supply) OResidential Water Supply(single) 0' M in.'
gin 10 Commenial ORcmdent ud Water Supply(shared) 1&GMUT
FROM TO MATERIAL l`EILffi7i METHOD&AMOUNT
' ens IL LA ' R
NowWater Supply Well:
OMan toting ❑Recovery R R
Injection We": R R
OAgaiferRecharge ❑GroundwaterRemediation MSANDIGRAVF.LPACB
FROM TO MATERIAL nVLACFI4Mff
OAgoifaStorageaadRecovay OSaiinrtyBsaia R R
OAguiferTest ❑StamtwaterDreinege Un
R R
OEsperimental Technology OSabsidence Control
❑Geothermal(ClaedLoop) OTracs 2aIDRILLINGLMM attsetMultfoaelsieateY
FROM T DESCRIPTION ccbr, setthaM SkL etc
OGenthamal gnu
ingACooftlIctum) OOlhea( lain Dthded#21 Remarks) R R
fG R r
4.Date Wells)Completed: 7 .
R R
S.We0/�, R R
R R
Facility/OwncName Facility M#(if applicable) tit R
R R
Plty/s Address,CM®d2ap IL REMAItSB
CormLy Parcel IdendfieatianNo.0110
36.�/ffiude,and Longitude In der teslaeconds or decimal degtes: 22.Certification:
(if well field,one lst/lotsg is sufficient)
of Certified Well Conbaeaar
6.Is(are)the weQ(s vmueut or ❑Temporary BY•,fgmng**form,I hereby aen*that ire weft(d scar(were)construvird or accordm w
�/n with 114 NCAC 02C.01W or 1S.t NC4C j02C.0200 Wel Combruction Standards and There a
7.h this a repair to an eiistin well: OYes or C-_ copy of this record has been providsd to the well owner.
If thts tr a tepab,jW.aWbuma weU cony&%wdon c formation and espbrirt the naave ofThe
repair rider 921 remarfa section or an the boat afthis form 23.Ske dingmin or s dditlooal well details:
You may on the bank of this page to pravide additional well site details or well
L Number of wells conshuded: conshuction details. You may also attach adclitional pages if necessary.
Formur*k mjecdarr or n wafwrmWfywellr ONLY wdh ire wise eaattrreten,you can
submit ore form 24.Submittal Instructions-
9 Total well depth below land surface: (R.) 24a. For An Well; Submit this form within 30 days of completion of well
For rmdhple weEslat all depths ff different(aemrrple-3WOO'nand 2@IW) conetnu Lion to the following:
10.Static water trust below top ofemdtg; j V (�) DWhion of Water Qua ft,Informadon Pt uceaekg Unit,
tjrradrr level is above casing;use-+^ 1617 Mall Saviee Center,Raleigh,NC 27699-1617
Iq
11.Borehole dm iaeter. v (in.) 24b.For IniecILM Well: In addition to sending the form to the whims in 24a
above,abo submit a copy of this farm within 30 days of completion of well
12.Wan construction method: t J�� J`�� construction to the following•.
(Le.suM totmy cable,dseet push etc-) DF j
vis[on of Water Quality,Uodetgrotmd Injection Centtol Ptogtam,
13.FOR WATER SUPPLY WELLS ONLY: 106 MM Service Caiter,RWOFA NC 27699-1636
13a.Yield Wsm) Method of teat: 24c.For Water Summhr-&Ge odazm l Wens: Fes addition to smdrtng the form to
the address(es)above; also submit one copy of this form wid do 30 days of
131L Dhdnfeetiou type: Amotmt: completion of well construction to the county health dgmtmmt of the county
Where constructed
Forst GW-1 Nmth Cerolia Depa tnmm ofFavnammem and Nanaal Resources—Division of Water Qos* Revised IwL 2013
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