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HomeMy WebLinkAboutGW1-2021-03397_Well Construction - GW1_20210607 FELL CONSTRUCTION RECORD ForlatcoW use ONLY: This form C!u be used-for single or multiple wells L Well Cootrsctur IDforatatl6n: D RECEIVE 14 wwT1?11Z01� € Ronald E: Keetel•Jr.. FROM TO DEtCRIptiON VveUCoi>ttactarName JU % rL 1 2960-A Unit ft " NeweueoasaetorcerdfigrioaNuuber Ir�tarr.ation pro., µ5irlg 1S.OUrERCASQIG rsdtEoesdwe8 ORI11� ©t� R se-Jon FROM TO DIAMETFB- TH[Crt1+F8s MATERIAL Southeastem Pump&Well Service Inca + - - Castpnn)tName /� f }�1 1B 1PIIVEB CA.41Nf'CIHTIlSING clod 1 FROM TO MLIFX DIA THICT 'IS MATERW. ; 2.Well Construction � Permit ) J r t it 1t to List all aMpliaabbe welt aoiurisrctlon prrmirs(is.Comttp,Sap.VarioacR steel t fL is 3.Well Use(ebeck well toe). 17.SC1kM Water Supply Well: FROM TO DIAMLRTR 91DT S= Tluelanm I MATmuw OAgrienlhttal bhc 440 tr DOwthermal(Heating/Cooling Supply) pResi'dxttial Water Supply(single) rt. tc to ❑htdustrial/Commercial ORcaid hal water Supply(shared) ig&ROUT FROM TO MATERIAL EMPLACVWZK'MEIAOD&AMOUNT clirrigation C> R it NoerWitter Supply Well: !� R OMmrtodag PRocovery well:Injection tt IL OAgoifarReehatge OCmundwalerReae3iatim 11SAN WGRAYELPACB Of assisDa6k) OAqu&r Sttxage nerd Recovery OSa1j�y Beajer FROM TO MATERIAL EM4LACEtNFNI MtSIHOD OAgaiferTest OStormaatwDrniaage tL OEVaimenW Toohnology OSubsidence Control 3ADR LLMGLOG attaeiad�timetsiae4P ❑Owthe mal(Closed Loop) OTreoer FROM To DEsc rtox mror saturant sk rc a r3Geothamai(A ' Rdnm) OOth� leis turda 021 Remob) >X 2 4.Date Well(r)Completed: - & Will I~1llt� rt, to FecrTiry/ Name cr e-A,6Feeilityw#(ifappt4ceble)6aA M ffi ncjid % R P teal Address.CAy,wd;Up 2L BF.htARKB Ow* Percet IdeedficaucoNo.(PIN) ft Latitude and Iaostgitude is degl ees/asiaateafseeoada or dadmal deSreew 22.cor"catloao,�••�a---.—— (if well roll,am ler/10 g it sr$gienr) ��''��� � e.sR Q N.�.la� 1 �] W %4catumcfCafiflodWeItCantractor Dete 6.Ia(ate)the well(ax or OTempotat7 By sigrmR drirf.M I&,rby,x,,*Hrat'tha w ll(o was 6r w)owrubraard w asm dmrre with 1S!NCAC 02C.0100 or 13ANCAC 02C.0200Wef Ccm*uedon Smsdmds ond that a 7,h this a repairto an exhli erg well: OYes or caYy al dris record leas beery prvvidrd to du wet?owner. if drir it a,"h fII oatb w"wen mudvcdoe irrfa mown espker tlu we"of dye repair seder#21,e wfu see ion or on du book offldtfa m 23.Site diagram or addttlotsai well details: You may use the be*of this pages to provide additimal wen site details or well L Number of wets core noted: conetruetim details. You may ahto attach additional pages if ucomery. Farmdtwk frgectfmt or aoe►warnat pplyweUrONLYwirk&e sane emv6, ff,,i you oat submit oar fumy. 24.Submittal Irstrudi m: 9 Total wdi depth below laud surface: (fL) 24 L For All Wells Submit this form within 30 days of completion of wen For multiple wefts listaIIdspOa ifdprew(=z*s-3W00'4W2®100') wonuadw W the fonowiag: 10.Statue water level beiew top of easing: 'c) OQ Dividon of water QMality lufarmatloo Pmceadog Units fjwafw level is abase carfng,use�; 1617 MoR Swdw Center,Raleigh„NC 2709-1617 11.Borehole dbuneter. t% (1n) 24b.Eor IniecOw Wells: In addition to sending the form to the address in 24a above,oho to the a Massing: of this form"with se 30 t3eya of completion of sera 12.web eeaa,trocehta nseHseed: �a construction to the fonowingr '. (te w*-,rutsy,cab*direct push eta.) Dtalsiaa of Water Qaalliy,UoderErotmd Injeetim Coated Program, 13.FOR WATER,SUUPMY WELLS ONLY: 1636 Mall Service Cent 6,Raleigh,NC 27699-1636 13a.Yield c Method of 24c. Water gip*do t�mt�mr-1 "1 i1a: !n addition to sending the form to the address(ce)above, also submit one ixpy of this form within 30 days of 13h Disinfectiontypal Atteotmt: completim of wen ooastructim to the county health dtpiotment of the ceantp whore constructed i Form OW-1 N-*Csmb-Deper4imtof ardxait dltmmnm—DtvmmofwaterQaahty Revisedleo.2013 x