GW1-2021-08148_Well Construction - GW1_20211109

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WELL CONSTRUCTION RECORD
This form can be uud for single or mukiple we11s Far Internal Use ONLY:
1.Well Contractor Intmmatioo:
Ronald E: Keeter Jr.. 1t WATER ZONES
FRAM TO DESCRIMON
Well Contract-Name R f
2960-A R R �r
NC Well Conwdctor Certification Number 15 OUTER CASM saki-eased we OR LUOR Of
FROM 1 TO DIAMETER- TMCRMN 1 MATERIAL
Southeastem Pump &Well Service Inc. & I-)
Company Name 161PII�6 OBTOBIIV[' load
FROM ITO DiAME'eA TMCKE TFQLIL
2.Well Construction Permit#: R
Ltd all applicable well cmuvaction permits(ke.Covmy,Smm.VarlwoM era) -
R tLis
3.Well Use(check well use): 19.SC1tEEN
Water Supply Well: FROM TO I DIAMETER I grnrstZE I Tm uneNESS
OAgriculturai OManicipaVPablic h' tL hL
❑cmthermal(Heat;'_.,kpJCooling Supply) OReeidential Water Supply(single) ff. tL ton
❑Don Commer w []Residential Wste Supply(shmed) I1 GROUT
ati0n
FROM TO MATERIAL EMPLACI M ITMETHOD&AMOANT
R R
Non-Water supply well: R
OMunifaring ORccovery IL
Injection Well: R R
OAgaif-Rechaege OCaoundwstarRemediatim IRSADD)/GlIAVFLPACH
FROM I TO MATERLIL EMPLACEMENT METHOD
OAquifer Storage and Recovery OSalinky Barrier tLR
OAquiferTat OStamwaterDremage i
OFxperimeatai Technology OSubsidcnw Ca*ol I
R R
OGoothe:mal(Closed Loop) OTraer 206 DBILLINGLOG aetaeiad monat sheets ff
FROM TO DESCRD?rION tutor.hEMbM§dVM&rMbMIS IkL etc.
OGeoUlenml alicatingfiCoafing Return) C30thcr(cKplain under#21 Remarks) R n G1
R IL4.Date Wells)Completed:
. R R
Will Lo on: R R
R R
Faaky/ ame FeeilityIIJO(ifepp(icahle) R IL u
11 LJ1 �l R RNOV
hpical Address,City,and Zip IL RE6lA1tSB 9
C—MLY PmmlIdmm&atianNo.(PIN)
SL Latitude and Longitude in,deg.ms/minades/seeonds or decimal degrees: 22.CertMcadon:
(if well r1 e14 one is suffrciam) / Q�
AIL N
' IrSip3ture of Certified well Conaeda D
6.Is(are)the wel)(s} or OTernpor s ry
By signing thirfomg 1 hereby own*tha Ww weII(s)was(were)cautr=W in accardw=
with 114 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Came mcdan Sriurdardr and that a
7.L this a repair to an existing wrcil: OYes or No copy of thtr record has been p vukd to thr well awmr.
If di&is a repair,jW mrknown well cvw&ucdon irformatien and eghrk the nave of die
repair corder d21 mnm*r seeder ar oa the book of flwjbrm 23.She diagram or additional well details:
You may use the back of this page to provide additimal well site details or well
L Number of wells constructed: censhuction details. You may also atlsdt additional pages if necessary.
Fornniti knfectianornorrwahrmgplyw*VsONLPwiththeamreeaasbsrdhen,youern,
submit one form. 24.Submittal Inwbuctioos:
9.Total well depth below land surface: � (R.) 24a. For Ali Wells-, Submit this form within 30 days cf completion of well
For nuMple we&list aff depda if df&va(asmnphe-3@200'and 2®1W) construction to the following:
Division of Water ,
10.Statle water Irvsi below top of easing: I� (ti) Qoahky,.Information Processing Unit,
If"trr level is above carft use"t^ 1617 Mail Setvlee Center,Raleigh,NC 17699-1617
11.1loneMk diameter._ (In) 24h For Injection Welt: In addition to sending the form to die address in 24a
12.Well construction method: le" \ ./�1 above, ti o submit a copy of this four within 30 days completion of well
1J conahvetion to the Mowing.
(Le.urge;rotery,cable,di ect pints,etc.)
Division of water Quality,Undetjrosmd Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13e.Yield(gpm) Method of test 24c.For Water Sug*de c, a1 W-dh: Tor addition to sending the form to
the address(-)above, also submit one copy of this form within 30 days of
13L Disinfection types Amount: r completion of well conatuctim to the!county he4dth department of the county
where contracted II
Fomm GW-1 North Caolim Deparhuer t ofEnvir�and Natural Resouran-Division of Water Quiiry Revised Tea 2013