GW1-2021-08160_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD For Intemsl Use ONLY:
Phis fans ens be used-for single or multiple wells
L Well Contractor Infwetadcn: f S
Ronald E:NKeeter Jr.. 11 WATMZOM
FROM TO DESCRD'IION
wevernei,err:xame _ R tt
2960-A n ft �
14C well cmtmctarcasfiwmnNumher MOUTERCA.4Ir7G anilt4asedweL ORbIl�R
FROM TO DIAbtEM• THICNN=
Southeastem Pump &Well Service Inca r I `
Company Noma Fn�1MROM TO DIAMETW THICI[tM MATERLIL .
L Well Censtruedon permft it.
Lid aff appikable wr0 mamnettanpasrfrr(L7<.Covri};Swm,Yariar,eo.OW
R R is
3.WA Use(cbedcwell user 17.SCIZEEFIV
Water Su>ppl7 Well: FROM TO DIAelETrR. SLOT SIZE Tmclon S
QAgricultaral Mier rL ft, IV
❑Goothcmal(FIeating/Cooling Supply) , Reaidential Water Supply(sin&) 0' ft to i
Ohtdushial/Cosnme'rmial ORcsidential Water Supply(eharcM IS GROUT
FROM R TO EdtPLAQM1M HOD&AMOIINT
Olin m
Non-Water Supply Well: O IL
OMmitadng ccovery iti
OR
Injection well: m ft
QAgaif-Recharge OCaanndvAdwRemodiation PAC B
OAtpuf-StotageahtlRoowey, OSalinityBacrier FROM TOr I MATERIAL METHOD
OAgniferTeet R
QStotmvveterDtainage
IL IL
OEXPetimental Technology OSubsidenw Control
20.DRILLR+TGLAW ateri0"Woodaestsr
OGeothermal(0eaod Loop) Mrsar FROM TO D ON color satYract< sa ere
OGM11101mal(A ' Retom) 1301ha( lain nodes#2I Rcmarb) 0 ILA"
m Q1 ,
4.Doe Wdl(s)Completed: l
ft.
5.win Location: IL ft
ft
ft
Facility/OwnerName FecilityMN(ifWlicable)
M & OZ1
=VC-AC
hilddCtty, 7rp 2LREMABSB
,
COMMLY
-SL Latitude and twShude In dep nottaimota/aerneds or deelmai degrees: 22.Certification:
(if well Feld,am hdllong is au")
Signahae of Qertitied Wall C ftaetor
6.L(are)the we9(ar emaaeat or OTetnporary BY M9—W d-f-M I hereby an*that the well(s was(were)earssbaehd in aczv„da,cee
with 15A NCdC 02C.01W or 13d NC1C 02C.02W We f Construction Standards and dart a
7.la this a repair to an eafsdoll weft• Oyes or o copy of tW record har been provi&d to the well owner. '
If thb tr a repov,JIU orrtbmwn wdl cvns6vedoa tsfarnraboa and ezplaBt the nanrre ojrhe
repair sader s21 remarlas agan arm the back o+fthis firm. 23.Site diagram or addfduoai well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells mm&ucted: construction detaile. You may also attach additional pages if necessary.
Formu&pls byedim or ron watrrj&Wp,weUrONLY wt k the awe easatrrefon.you can
mbradaseform. 24.Submittal Insteuedens:
9.Total well depd nd t below la eaefacet a�. (R:) 24 L For All Welts: Submit this foim within 30 days of completion of wcli
For nsrUiple we11t list a!1 drpda if dfffrrent(a maph-3®200'and 26100) consftction to the following:
10.Sbdk water level below top erf easlogt '\� (fL) Division of Water Quality,Infor�madon Processing Unit,
fjsrabrr level it above ca ft rue 1617 Mall Service Center,Ra ftk NC 27699-1617
11.Boeelwk diameter. (hL) 24L For Infection 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: \ (--)A art t consh=ticn to the following:
(Le.mism;may.eabk cheat push,etc.)
Division of water Que ty,Un der irormd Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Coder,Rdeigbr NC 27699-1636
131L Yidd(gpm) C Metbod oritkat: 24c.For Water Suenk&Geodgmal wells: bn addition to sending the foam to
L_ :RttE
the addrses(es)abwy also submit one copy of this form within 30 days of
13L Dbdnfeedon type:_ -7� LL Arun®!: completion of well construction to the'county health department of the county
wham conattacted
Foust GW-1 Naath Carolina Departnem ofEnvuonmemt and Natural Resources-Drvismn of Wmer Qoelay Revised Jan.2013
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