GW1-2021-03413_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD
For Iahrml Use ONLY:
This farm sees be u±ed•for sunk err multiple wells '�
L Well CortractwInfo:matioe: ��`j
Ronald E..K'eeter Jr.. 14.WATFBZONFB
FROM TO DFSCRPTION
Well ColttracttrNeme J v VIL
2960-A psed's5Ing U ' fL fLi
NCWeUContraciarCatificabouNumber �n�o( 'a on 1SOUEMCASING sultl�d wsL ORLAVSR
FROM 1 TO DIAMETER• I TMCKNEsa MArrztlnL
Southeastem Pump &Well Service Inc. fL = �.
Company Name - 16 II�Iln>!�CA.4a7<'ORTtA1IIHG dried
FROM TO DtAMETf4l TMCKNF.98 MATERIAL .
2.Well Comfrsctlon Permit A tL 1L ter.
Lfn all cWiaobk-9 oornarcrfon p-mfn(fs,c--y,Stan.Varis:see,eta)
fL fL
3.Well Use(check well me). 17.
SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE KNEss TERIAL
❑Agricultural iL n le
QGeothetmal Of-fng/Cooling Supply) Rif9idential Wets Saleply(single) X fL in
Qhtrhratrial/Cammeeeinl ORaideatial Water Supply(shared) 18 GROUT
FROM TO MATERIAL &AMOUNT
akrigation
Non-Witter supply well: k 1
OMmitoring Olt—very R &
Injection Well: fL IL
OAgoiferReoharge QCumndwaterRemedistim 19lSANDIGIlAVFl.PACH
FROM TO MATE RMPLACZMW METHOD
OAquiferStotage'and Reaavay QSalin3yBaaia
OAfNifetTest OStarmwaterDtainege n -
OFxpe:immtal Technology QSubsidence Control
IR DR1L:"T"LOG sllseD addki=d dmsb tf
weothe:mal(Closed Loop) OTraoer FROM TO DEscRSTION tmbr.burdam seOndet rim EA3011keta
OGeothormal(H Rehm) OOtha( hmmmder#21 Rtmtarta) fL
• Zk L Date wells)Completed: 5o
S.Will Loea*M:
�` tt �
J (L fL
e`O �Alh �/1/� �� � IIJ
11 Feeilrtyft(if se Ibb) L fL
&
"bys'ia(l�Ad&ess isty.m/d�Zip
�Vl ll L �1-IL
ILBEd1ARS8
Caucty Parcel Ide:rificetionNo.(PIN)
3b.Latitude and Longitude in dep walminutestiseconds or dermal degrees:
if wall held,Onelat/lorg 22.Certification:
A CA
Smut re of Cer iSed Wall Contractor Data
6.Is(ace)the wewKsr ermsoent or OTemporary BY d8 ME&W fmM I heroby aft*tint the velfN was(were)ca druckd in a=ordmrce
with ISA AVAC 62C.01W or 15A NCAC 02C.0200 Well Conse wetkm Standards and that a
7.Is this a repair to an esistleg weQ: Dyes or copy j1 do record has been provtdrd to the well owner,
If detr k a repair;fir asetArwwn we(I coastrvcdoa u format»r nerd esplmh the naeve of the
repair order fe21 remarbaeedm arm du boat of thir)bmc 23.She dlagm or additional well details:
You may use the back of this page to provide additional well site details or well
S.N®ber of wells contrasted: construction details. YOU may also attach additional pages if necessary.
Foremddpk infedfwr or nor►waor sup*welk OAMYwith dro sane eaieebaedam you can
submitaar•luem. 24.Submittal Ins&ucdotas:
9 Tatal well depth below bard surface: `f'�tLJ. (fL) 24a.For An Wells: Submit this form within 30 days of completion of well
For rmdtiple wells fista0depthstfdiffe raw(eaampir-8@200'asd2@1W) construction to thefollawhW
10.Stade water level below top of eardrg: (ft) Division of water QaalkY laformation Proeesahg Unit,
if wafer level is above caFft usew f( 1617 Mal Service Carrier,Raleigh,NC 2709-1617
m 11.Borehole diameter nn y MO 24L For Injection wdh: m addition to sending the form to the adrim.in'24a
above,aho'submit.a copy of this form within 30 days of completion of well
12.Well construction neefhod: \ lJ�l 1LJ lJ�.�� construction to the following:
(Le.mrge%tatery,sable,dueetpash,eb.)
Division of WainerQaaHty,Underground InjeetloD C0n&Q1 Pmgmuh
13.FOR WATER SUPPLY wEIM ONLY: 16M Mrdl Serekr Center,Raleigh,NC 2709-16M -
13a.Yleld(gpm) r Method of test: 24e.Far Water Stook&Genthe d Wells- In additim to sending the farm to
the address(es)above, also submit one copy of this foam within 30 days of
13L DWnfkt m type: Amo®t: completion of well oaostruatim to the county health department of the county
where constructed.
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Fan GW-1 Nasth Carolina Depmtrtmm ofEavisontneat and Natural Raaaus-Divisionof Waier Qua I Revered fen 2013
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