GW1-2021-08145_Well Construction - GW1_20211109

WELL CONTRUCTION RECORD ForIatcmal Use ONLY-
This foam can be used-for single or.multiple wells
I
I.Well ContractorIufnemation:
Ronald E.: -Keeter Jr. 1 14.WATER ZOI�S
FROM TO DESCRIFI'ION
Well Cohtr"Name it
2960-A M tt:
NCpWellCouaetarCert icabonNu=ber 11 OUTER CASM aulNtredweL ORLINER
Southeastern Pump &Well Servi FROM fL Inc. �.TO DUM M t•X. TMCKNEW MATIMAL
1.
Company Name 1'�
�e 1 II E &�II�& OR TURDM; dse
t FROM TO DtAb�rE;r THICKNESS MATEBLIL
2.Well Coustrwdon Permit# jj�� f6 is
Lia all applicable wa0 corcarrrctian pmn¢s(is.CormW,Stare,Varian,era)
R R in.
3.Wdl Use(cheep well user 17.SCREEN
Water Supply Well: FROM I TO D swT sru THtC7Q0r86
❑Agricultural ❑MU I/Pnbtic ra tv '
❑(isothermal(Heating/Cooling Supply) �fReaidmtiel Water Supply(single) ft tt to
❑Lrdustrial/Commernial C1Reaidential Water Supply(shared) A GROUT
FROM TO MAIERML E6WI.ACII�iEtIT&MHOD&AMOUNT
❑Ilri slim
Non-Wafter Supply Wen:
❑Monitoring ❑Recovery
Injection W . R fL
❑Aquifer Recharge ❑Groundwater Remcdiation 19 SAPIDRr'RAYII.PAf3
FROM To hU RIAI EMPLACEMENC METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
OAquifer Teat ❑Stonnwderlhainage R
❑Expetimmtal Technology ❑Subsidence Control
❑Geothe:mat(Closed Loop) ❑Traces 2A DRILLD7GLOG attaeiaddiflo.d slash ff
FROM TO DESCRIPTION tutor hadsess,sal shk arc
OG"crIll(H Retuta) ❑Other( lain under#Z1Remarial)
` r
4.Date Wells)Completed: fL.
ME-1 2LL
r
S.Well Locii�iation,
� w IL
1p r �� ��1Abdo fL m
Facility/OwacName ecilityMN(ifepplieable) g -
ft.hys
real Aeidreys fly,sad Zip 2L REMARKS
' QSk
r
County PermlIder ionNo.(PII� ,y t;F;
SL Latitude and Longitude in depf+eea/tdutedseroads or decimal decrees: 22.Ctxtlilcation•
if well fie bolo g is sufficient)
--��
N� W
d "
� of Cectifmd Wdl Cwtreeh�
AP
li.Ia(are)the wei!(sr ermaneut or ❑Temporary
BY signing dtirfosrg 1 hereby arrrJy Nut till wells)was(were)carrs6sachd in accordance
with 114 MAC 02C.OIOb or!SA NGfC OZC.0200 We0 Conaruetion Standards and that a
7.Is this a repair to an existing well: ❑Yes or rnpy g(tkJ record has been prwtdrd to:&well owner.
If thb leer repab;frD art brown well mrrrtrrrcaoa v formatbn and esplavr the nature of du
repair ruder#21 renzw b reckon or or the book of thir)brm. 23.Site ding am or addltiond well details:
f You may use the back of this page to provide additional wen site details or well
&Number of wens constructed: \ construction details. Yon may also attach additional page if necasmy.
For maltiple ngeclion or ror}wat►r supply weUr ONLY with die sore eaerbredon.you can
submit ore form. 24.Submittal L ubmetiom:
9.Total well depth below land surface: �( 24a. For All Welts: Submit this form within 30 r(t!.) days �compktioD`of well
For rmrTNple wells list all depda if ffliresd(=w7le-3@200 g:
and 2(plw) construction to the followin
10.Static water level below top of earlog: VC) (M) DWWoo of Water Quatlty,laformation Processing Unit,
fjivater level it above casing use".+�" � 1617 Mail Service Cattier,Rakish,NC 27699-1617
11.Borehole diameter. _(1n.) 24b.For Inleetion Wdh: In addition to sending the faun to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well eonstrawtlon tnRtirod: ,\�l11 f`.�} construction to the following: i -v
(le.eugen rotary.cable6 seat push,etc_)
Division of Water Quality,U-krgrormd Injection Conhd Program,
13.FOR WATER SUPPLY WELLS ONLY. 1636 Mall Service Center,Rakish,NC 276994a6
132.Yield(Um) CNA
I v Metbod of teat 24c.For Watrr Suooiv_ds W, 1M e : In addition to sending the form to
the eddeesa(a)above, also submit one copy of this form within 30 days of
completion of well oonshuctieu to the county health.:department of the cam :,...
136.Dtafnfeetion type: Arnotmt: tY�:
Where eeMftUCted. C
Form OW-1 Ninth Carolina DePubw d of Favaormmeoi and Natural Resmaua—Div-i"of Water Quality' Revised Lea.2013
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