GW1-2021-06900_Well Construction - GW1_20210505

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WELL CU1ySTRUCTION RECORD Foritctema111eeoNLY:
This farm c®be toed fo`siogle or multiple wells
1.Well Conuudar Inknnation:
11 WATERZOMM
-Ronald Ec%Keeter Jr.. FROM TO i DESCRIPTION
weir Coatreaar xame k k iG tt
2960-A n �.
NC wellCotoraetarCettificatioaNuatber IS OUTER CAMM seriltlearedwe6 OR7��ft
FROM TO Dteserrm•i TffiCYPTTE38 MATI*StIAL
Southeastern Pump &Well Service Inca O + It
Company Natae lr%D aM CAB►ve-ORTUSDVr fiesalbormiddamed-low)---
FROM 70 DtA1tEIEIC THICKNE44 MATIItIAL ' •
Z Well Construction Permit#sald-NIA R R ts.
Lid all applicable wvg awubucdan pmnils(LT.CM-Y.Stets.Va -dI6 eta)
Fm
gas-- -
3.Well Use(cLediwell met 17 SC>:EEEN
Water Supply Well: FROM 1 TO I
1DIANM= SLOT SEM TMCIQDn= MATERIAL
❑Agricaltural pai/Public �R `Ll m 4 v C•
OGcothetmal(Heating/Cooliug Supply) AdResisicatial Watt Supply(single) IL
OlndushisUCommemial OResidential Water Supply(shored) 11 GROUT
FROM TO MAT68IAL EMPI.ACH1D,rNTMEIIIADAAMOUNT
on to n
Non-Water Supply well: M m
OMonitoring OR—very fL Injection Well:
ft.
pAq:Iiferltaharge OGsoundwabwRrmediation i9lFROM SANQ1G4AYELPAI�
gaiferStotageandRwovcy OSaTinityllsrricr '`O ;n i � IL wrw EMPt.AC
OA M>ri$oD
OAgaifaTest OStamwaterIhainage & w L
OFxpaimmtal Technology OSubsid=c Control
zttDBII.LINGLOG IfEecallawO
OGoothamal(Closed Loop) OTraeQ FROM I To DBOMMONIcalar. sdvsodc sec era
Moodurmal(HcstkgCpd• Retain) OOtita( Ltinuttdrr#2lRtmstim) n f=n&
4.Date Well(.)Completed: V C]�.� �. , .
`�S.Wil-lMLocaattion: fa to
O ft
Facility/OwnerName Faeilitymo(ifepplirable) ft. fL
n2 den n ft
�hrical Adc1tem City,and Zip IL REMAIM °c'
�t��'�i�l� _��•,- '?rn{negil'tt 1.;i111
catay Pascal Ideatifieatiaallo.(PIIO u.uvc�•, �� ey 1rti0il
5L Latitude and Lmrgft de In degr a or detdmal de8rees: 2L Certification:
(If well field,air kulm*is suffteanti)
of Ce dw well000
CoflLador
6 h(are)the wen(s): a manent or OTenlporasy By erg rfng Air fain►I hereby certify that tha well(.d was(were)c+an&uc iedd in aacordm ore
with 114 ACAC 02C.0100 or 154 NCAC MC.02W Weff Coasbucdan Sta dardr mid that a
7.h this a repair to an etdsthsg weib Oyes or o copy grAb reowd has been provided to the wen owner. '
If thin is a rgx&,JM ontlmown well cornbsrc6ax infonaatkIs esouk d.tame of tlr
report toiler 021►emarbs than or ore the boat:cffAwform You
m use the
orck e f thisdlli wet defafis:
You may use the back of this page to provide additional well site details or well
ti.Number of walls constructed: ceosbuction details. YOU
may also a"adt additional pages if accessary.
Formuroplr agectim or nonwaorsepplyweasOlV1-ywAh the lace edmbcddom you emr
svbnti<one form 24.Submiaal Instructions:
9.Total well depth below land surface• ' • (ft.) 24sL For All Wetat Submit this fain within 30 days completion of wet
Fornmaiplewearlistal►depantfdjferae(ex aWs-3®200'aid2®1W) coashactiouto the following:
10.9tafle water level below top of easing: 10 Dlvhion of Water Quatty,ifformatioes Recessive Unks
ffwabrr lever is above eosin&sae 1617 Man Service Center,Raleigh,NC 276WI617
il.Bm:hok diameter. I 00 24L For niectiou Weir. In addition to sending the form to the addmi in 248
above,aho'submit.a copy of this form within 30 days of completion of well
12.Wen cooehuctian method: 11 eonehnction to the following:
rotary,eeblq direct push ate) Division of Water Qua ft,Underyroemd Injection Couftel Pnwmn r
13.FOR WATER SUPPLY WELLS ONLY: 1636 Ka Betake Centety Raleigh,NC 27699-1636
13a.Yield 20 Mewed of feet: 24c.For Water Su_edv do fmtltermni Wets: in addition to smdmg the fain to
) the adsims(m)above, also submit one copy of this form within 30 days of
ttT /1 compktion of well coustmclias to 6te county health dep l meat of the County
13h Disinfection type: Aruotmt• where constmcted.
Form GW-1 NorthCorohna Depmtumat ofFswamnsaea andNattaal Resaacea—Divan-of Water Quality Revised lea 2013
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