GW1-2021-08144_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD ---
For lntemal Use ONLY:
This form can 6e used for eirgle or multiple wells f
L Well Contractor Information:
Ronald E: Keeter Jr. IL WATMZOM i
FROM TO DTSCRIMOII
WeDCohheetaName --
2960-A IL rL
NC Well Cotxrecta CeitifieationNum1= ISO CASM ffwsuit!eased wed OR LMIR
FROM TO DIAa1tiTER URCKRM TPSLIAL
Southeastem Pump &Well Service Inc. m = J UL
Company Neme ^� !ti IIuOuilM terrors_
FROM I TO I DIAMfrTrV_ TMCXZMS MATI<BIAL
2.Well Construction Permit t.>( (J tL u _
List all applicobte we0 oonrtrrretlon pemrirs(iY.Corsny,Sonar,Vorianee em)
ft tt ion.
3.Well Use(check well me). 1�C[RAirN
Water Supply Wed: FROM TO D1AME TR SLOT SIZE TMCKMM IMATERIAL
❑Agricultural blic t7 l a> U
OGcothcrmal(11cating(Cooling Supply) Residential Water Supply(single) ft Yp ter'
OlndustriallCommereial ❑Residential Water Supply(shared) Ili CDT
FROM TO MATERIAL EbWLACFII ZNT METAOD d<AMOTJNT
am ation
Non-water supply wen: m 'L
OMdnitoring ORecovay R ft
Injection well: rL tL
OAgeiferRecharge OCuoundwaterRemediation I 19.SANDIGRAVELPACB
OAquiferStorage and Recovery OSafinky 138>Tier FROM TO MAIERiAL EMPLACt>7WM
n tG
0 Aquifer Test - OStormwaterlhainage
0Fapm9mmtal Technology OSubsidence Contmi
❑Geothermal(ClasedLoop) ❑Tracer 7ADHILLiNGLOG stdeladdRfoasitlaabi<
PROM TO DESCR>p1ION sobs sdVM&4M am, skk art
O Return) ❑ot ( lm under Reab) �tti
4.
4:Deft Weds)Completed: R tt s
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m ft.
Fac rl, lowner Neese Facility ID0(ifappiicabb)
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r +� k City and Zip 2L REMARHS NOV 9
;ken .
C-MLy Pmeel Ideabfteation erns(PII�
5b.Latitude and Iongttilde In degeeslminutedsecouds or dedn al degrees: 22.Certification:
(if well Field am' °�is s,>&cmnt)
of N W
`Signahae of Catifwd Well cam4nact
6 Is(are)the we@(s}fdPermaaeDt or OTemporary By J'9mn9&-faM 1 h—by OW6 A&the weD(d wog(wess)cautr rcted at a=rdma e
with 1 St MAC 02C.01W or MA NCAC 02C.0200 Wed Construction Standards and tint a
7.Is this a repair to an existing welk ❑Yes or o copy of thit record has been provided to dw weR owner.
lfdtir is a repair,frD ad brown.well construction fr formation arrd explaar dw nature of the
repair wder#21 mnarbseetimr or on Ste boa*of thisjorrn 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
&Number of wets constructed: construction details. YOU may also attach additional pages if necessary.
For maltrple byectioa or nwo-watrrAWsly well,ONLY with the sale eaesbrot"en,you can
submitoneform. 24.Submittal I ctrretiown
9.Total well depth below land surface: (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For rmtlti*wcIIs fat a0 deo fdfj)irrent(esmnpfe O(�and 2®100F) constriction to the follov&r.
10.Static water level below top of taring: Tc W(ti) Divoo of water Qaadty.Itdormation Processing Unit,
((avatar Inv/w above ctrsin use"+'Q 1617 Mail Seiviee Center,Raleigh,NC 2709-1617
11.Borehole diameter. u (ion) 24L For Infection Wells: In addition to sending the form to the address in 24a
A above,she submit a copy of this foam within 30 days of completion of well
12.Wes construction method:�ArA`_��l construction to the following:
(La.sugar.rotary,cable,drect pussk ctc.)
Division of Water Qua ty,UndeeErour d Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: n 1636 Nk@ Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Suoely&Geol6e 3ke Wdls: In addition to sending the form to
TTTT�� the address(-)above, also submit one copy of this form within 30 days of
136 I36dnferlMn type: Amount: oompiction of well construction to the county health department of the county
where constructed
Form GW-1 Nmfh Carohns Depmtrneut of Eevi omnem and Natural Reso=s-Division of Water Quality Revised lac 2013
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