GW1-2021-08164_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD
This Form can be tned•forsmgb Or Multiple wells For fated Use ONLY:
1.Well ContructarinIbrustlon:
Ronald Es Keeter Jr.. ll WATERZOM i
M TO MERFRom
WallContradarNema R � h
29saA
NC Well Contactor Certification Number is OUTER CASING gararsiltl need wells ORLIIMM fif
Tmex7 Flw-
Southeastern Pump St Well Service Inc. ROM TO DL4bf TEQ Fnc. VI � 0. ��-
Company Name ] o (` �/ FROM R CA.SQii'OBTOBIIR'
J�` FROM TO DLIblEIl1C TIDCI(flLr9S Mp-CFBIAL .
2.wen Condrtwdon Pa mit#:�, fL M i< -
List aU applteable went conritwsion permits(tv.Comity,Saar,varjowgR era)
3.well Use(chwk well user 17.scttEEeN
Water Sup*Well: ro DUIWZT It SLOTS THfC1QVFBa TT RIAI
❑Agricultural OMu ' pal/Pnblic ►i in. I
❑Geothtsmal(HeatinglCooling Supply) eardentiel Wets Supply(single) D' tt 10' V
OlndustrialtCommereial OResidential Water Supply(shared) IL GROUT
FROM TO MATERIAL Ohri atim EWtPIdCII1tElYI hfEfI3DD&AMOURT
1L [6
Nan-Wxtw supply well:
OMonitoring ORecovery m j
Injection m IL
OAgoif-Pecitarge QGramdwa rRemedietion M
LPACB
MATERIAL 7Mw-ACEW zMrMETHOD
OAquifer Storage cad Recovery OSelinityBank �
DAquiferTest OStolmwatcrlhainege
DFxpetimeatal Technology OSubsidenee Control
OGeothermel(Closed Loop) OTracer 2u DRILLING LOG affaer additional.[testa fr
FROM TO DESCRIPTION m adlhaet She.de.
O m6tharmal(H ReRrm) ❑Other( lain under#21 Remaria<) R tt .
a. IL /l
4.Doe.Weli(s)Completed: l
CA
S.Will LeeIL IL
n:
tL R
Facility/Ow�l�e acility IIJti(if appfzeayb)
��. ,C
tL
ical Addles,c and o l<c
� 1LREMA1t8B ; =r r/1_
Cry Parcel IdeabfieadcoNo.(PIN) Nov 02'
5L Lathude and Longitude in JL 0. $ deppees/ areeeoada or decimal degrees: 22.Certlticatloo:
if woII fie 1a1/long is atawn I,y
61 , Xjs W
l ,f
S*rature of Catifwd well Cantracbx D
6.Kam)the wells). ansrrent or OTemporat7 By ri f 1 hereby err*that tht weU si ww(ware)ciassbrated Si"mrdarres
with 15t NCAC 02C.01W or 13A NCAC WC.02W Weft Construction Staidardr and that a
7.L this a repair to an existing weU: OYes or o copy of"record has been pevided to the weU owner.
If dhit is a rgwtr,fsU aWbwwn weU cvnreuccon it for t,4,tla naive of the
►epmr under t'21 remarb mehan or an the beat oftHi form 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
Number of weYa comtrorted: 1 cMft=tion details. You may also attadr additional pages if necessary.
FormidlrpL ngectims or ron.watersnpphf wells ONLYwith the seen eaarbvncaan,you cm
submit oM form 24.Submittal Iastruedom:
9.Total well depth below land sm?ace: (fL) 24a. For AD Wells: Submit this form within 30 days of completion of well
For rmn&*welts lbt aD depdcs tf'diferaat(c=plsL-3@7W'orrd 2@IW) Construction to the f011oWing:
10.Statle water level below top of caatng: D (tL) Division of water Quality,.information Ptviceuhg Unit,
tfwater level u above carts&use"+^ 1617 fKaff Servke Center,Ralekk NC 276W1617
11.Borehole diameter. C5-1 1 r (io.) 24L For Inlcctlon Wells: In addition to sending the fora to the address in 24a
/1 above, also"submit a copy of this form within 30 days of completion of well
m 12.Well construction ethod: f-(A C AJ ), construction to the following:
(ie a%-.artery,cable,cheat Fria•cta)
Division of Water Quality,Uodetgrotmd Injection ContrW Program,
13.FOR WATER SUPPLY WELTS ONLY: 1636 Ma8 Service Center,Rafth,NC 27699-1636
130.Yield WM) o Method of test: 24c.For Water Suonly&G dwr—mot Wells: In addition to sending the form to
the address(es)above, also submit one copy of this form within 30 days of
13b.DWhal dtau type: Ate; completion of well construction to di county health department of the county
where constructed
Fort GW-1 North Caroline Deparbneat of F.nvuesment and Nattaal Resources-Division of Water Quelt y' Revised lea 2013
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