GW1-2021-08146_Well Construction - GW1_20211109

LL CONS CTION RECORD
771is farm eeo be uW..for single ormnitiple VMUS For latemal Use ONLY:
L Well ComVectwIuffinn dan:
Ronald-E:NKeeterJr.. 14.wwTsezorlPs
FROM I TO ON
We11C6htiitdaxems -_ !ti � tt � .
2960-A ;� 1`
NC Well Com.aetnr Cerdf➢=fionN=tcr IS 0177 3R CASING aoilffrased welh OR LIIVPR
FROMI TO • TBICKIMSB
MATFRiAL Southeastem Pump &Well Service Inc. fL � -DIAMETER
CoarpanyName /'� yam/ / �// 16II�IIVEBCA�iGOBTOBIlVG
K / U_! FROM TO DiA3�fIIC lyp
2.WeU Coontnsetlon Permit Ilr J � T��►:. • - -
List all Awl-ble—ft cnnrouermn M. l°
pamYs rii.�scone.variarreR era)
3.wen Use(cbecic weu mar
fL is
17.St7tEEN
wale!Supply well: FROM To DIAMIRl11 SLOT SIZE TI110El�8S TERIAL
OAgricnlhual Elmo . . biic i tc j IN hL
OGeothamal(Hesting/Cooling Supply) widentiai wale Supply(single) fL tti la
OhtdushiaUCanme,ciai Mcsidential water Supply(shored) 18 CDT
Ohri ation FROM TO MATERIAL EMPIAQFMENT JMI)d AMOUNi
Now water Supply Weu: f R
oM ng oRcoo rcry M fL
In W fL &
ElAquiferReclaTge [ChaandwsterRemedistion PACK
OAgurfer&=gc,=dRcc,,,.y OSe&nityBanier FROM atATERrnI.
o�� F.IIfFIAC19YliRYi METHOD
OAgoiferTesi r
OStosmwaLerIkainage
OEapaimeatal Technology OSubsidence Control ft.
OGeothetmal(Closed Loop) OTrsar 20.DRII.LIIriGLOG aambM mmaAb"f.lf
FROM TO DESCRiprtON
OGeathamal g Return) QOther( lain under#21 Remarlas) R. mbr sdYeaet sa d�
4.Dam.Wens)Completed I / .
1S We
fL" ft
Fecgity/OwnerNama fL &
Feeility(II}?H(ffapplicabk) p--.--- --
- n IL
rcal Address .and Zap
fL
2L EEMASBB
Caurry PareelI
dsrai�ionNo.(PIN)
Sb.LadtndeAnd
lic one defndeg�+eea/mhmdd/ aardeelmal
ifwell ........ .............. .._., ,
1d is s�cient) des' 22.CariMcadon:
6.Is(are)the well(sr or OTempw=7 Q,o wftm of Cett,sed well Camtractu Dste
—f By s+f+r+n8 dri,fomr,I hereby errt�y flsrt flu weft was(were)cm:u&vcled a a=rdm w
7.L this a repair to an exisdteg wen: OYn or p wkh 1SA hCAC 02C.olW err 1SA NCAC 02C.02w Wed Conrbvft6n Smrdard,sad dW a
If skits it a �d ropy 9rIW record her been p vvfd,d to the wa OWMA
,epab;J+7t.aatiaowa oven eanr6vetfon it form.W. esplads she na.ofew
repay rider 021 remanbrsecom arm Bra boat of Lf*jbrm. 23.She dhrg us or addltkoal wen dehlhs
&Number of welts eomtrrteted. ` You may use the back of this page to provide additional well site details or well
Far muldplr Uyectim a run-way, construction details. You may also attach add'etional pages if naxssary.
submdrnrfam �pph'we![rONLPwuhshemaeearabraffee,you cc"
' 24 Submittal Inshucdoas:
9 Total well depeh below land amfaee: 3 MI 24a. For An w t■: Submit this form within 30 days of completion of v,ell
FcrmaN*weDrlictalldtpfhstfdffererrtres mgp-3WOO-al�lpp� CpRgtnt pDtOthef011owing
10.Sterile water kcal below top of eashtps ' rrd® (ft.) Devisioo of Water 9-MY,hda narteon Plveeashg Ua%
�iwaarrlevel Bainseearb>&Am�•+�
1617 AM Sw vke Center,Rakff^NC 27699-1617
11.Borebok diameter. L (ter.) 24b.For addition to'sending the form to the address in 24s
12.Will comhvcyon met ��
hod:L L� /+ above, abo'submit.a copy of this font within 30 days of completion of well
(La Construction to the following:
�ems.eablq daeet pu,h,der.) _
13.FOR WATER SUPPLY WELLS ONLY: Division� ,C d Injecdon Coubvl Progwin,
,RWelgb,NC 27699-1636
IaL Yleld 0") Medbod of tnts V 1, 24e.For Waier S�.oeh de .«r1e.....st W dh, h addition to sen&M the fa,n to
--7 the addresses)above, alm submit one copy of this form within 30 days of
136.Dhdnhrtlan types l Ate; compktiat of well cerudmeti u to the'oaunty health department of the county
where constructed.
Fomt(3 W_i NaRh Csmlim DepesnnerR ofF.wuommew and NatmW gaomms_Divnim of Weser Quality Revised 7®.2013