GW1-2021-08158_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD Farinremal Use ONLY:
This fora can be used for siogle or multiple wells
I.Well Contractor Information: f
Ronald E:'Keeter Jr. 14.WATER ZONIM i
FROM TO DESCRIPTION
Well CoihIIaelar Name R
29saA R fL
NC Well CordraetorCettifivatKmNumber I&OUTER CASM ffw nalltleasidwed ORLIIHP3t
FROM TO DUMCM- I THICKNESS TERtAL
Southeastern Pump &Well Service Inc. + n. �. V C
Company Name 1fi INNER OR TUHTM elosad
FROM TO I DIAbMTF3C TAICKItF84 b1ATExtIAL
2.Well CousMstMon Permit#: fL fL
List all applicable wrII oossbwtfan (is.Comae,Strom,Vorianee eta)
fLR is.
3.WeU Use(check well user 17.SClt]?2+PI
Water Supply Well: FROM TO DIAMEM SWTS= TItICKNffiS MATE72LIL
❑Agricultural OMa 'npal/Public R id � V�
OGeothermal(Hesting/Cooling Supply) al Water Supply(single) ft tti la
l7lndusbriallCommeroial OReaidcnthd Water Supply(shared) la GROUT
FROM TO MATERIAL EMFIACFJ1�ElI bRTHOD&AMOUNT
Ohri .m R R i
Nos-Water Supply well:
obtaniitoring OR—v-y R fL
Injection Well: R R
0Agaifer Recharge OGramdwatcr Rcmediation 11 SANDJGRAVEL PAIR
O Aqu'if rStawg Recovery a end R OSalinity Barrier FROM To I MATERIAL EMFLACEMMU METHOD
� R 0AquiferTest 17StamaafcrIhainage fL fL
OExpaimmtal Technology OSubsidenoe Control
❑Geothermal(Cleaod Loop) OTrace 2o.DRUJMG LOG aftwb addidowd*Ases w
FROM TO DffiCRIpriON m edam eta
oGeothermal(A Belson) 008ra( lain under#21 Remarks) fL rZ R , .,
4.Date Welk)Competed:� � tk fL
R' R
S.Will Location:
/ y� R fLrn
{_ \�v i 1-�(! �r 0���t Lo S:. R fL
Facility/ Name FeeilitylDO(ifepplicabb) R R 1
-
R R
kcal Address,City. G`
2L REA ARSE 2021
County Parcal Idetmscatiatxo.c�>M
fib.Latitude and Longitude in degr a or decimal degrees: 22.CertiAhation:
(if well fold,am lat/iorg is sufficient)
i
N .� Rr
Sigoehae of Certified Well Comaebw Date
6 Is(are)the weQ(sr Permanent or OTempotary By,ice dfis f-M I hereby a,tify dfo?the weII(s)was(weft)comasrctrd in aavrdansct
with 114 NG4C 02C.0100 or 13d NC1 t72C.02W A4II ConTb uction Standards sad that a
7.L this a repair to an existing we0: oyes or o copy cf thin record has been prvvidsd to the well owtxr. "
If dtir is a repair,fiff.mt bwwn well mm&uctfon b formation a; he native of the t
repair wrder 021 remarks section or on the boc*of ainjbrm 23.Site diagram or additlontd well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach aMtienal pages if neceeeery.
Formultrple byeetim or nw►wattr.supply wile ONLY with ire ssae comstrveaon,you can
submit one farm. 22 24.Subadttal Imtruetiom:
9.Total well depth below land surface: l (fL) 24iL For AD Wells: Submit this form within 30 days of completion of well
For multiple weds list all depth if dfg'erant(ermnplr 3@2W'and 2®100') construction to the following:
10.Static ovate level below top of easing: 1 (fL) Dtvtdon of Water Quality,.IDfommtiou Proses ft Utdt,
if water level it above carftrg use" 1617 Muff Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. V (in.) 24L For Injection Wells-- In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Z construction to the following.
(Le.sum sotmy.cab*&=t pu,4 ctV.)
Division
13.FOR WATER SUPPLY WELLS ONLY: �Mall 5�ee C hndeilround�NC 2769OL1636
13a.Yleld(gym) Metlrod of test: rALD24c.For Water Suooly&Geatlh umil Wells: In addition to sending the form to
the addreag(es)above, also submit one!copy of this form within 30 days of
13b.Dtdnfecdon type:.�_o Anoo®t• completion of wed construction to the cannily health depar meat of the county
where combucted
Foon GW-1 North Carolina Department of Envuotmmem and Natural Resources-Division of Water Quality Revised Jan.2013
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