GW1-2021-08165_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD Fa<rn��l use ONLY:
This farm can be used-for single or multiple wells
1.Well Contractor Information:
Ronald E.- 'Keeter Jr.. 14.WATM ZOM
FROM TO DFSCRIMON
We1lContractaNeme '_
29saA R
NC Well Contractor Certification Number 110 CA.SatG web OR TMM afff
FROM TO 1111KETER- THICIOYFSS TFRIAL
Southeastern Pump &Well Service Inc. _
Company Neme 1611%4 B CAS1?4G OR TOFdIK'
(� FROM TO DUMECIIC TMCKNESS MATERIAL2.Well Construction Peru*# Jamo co�1 h• & �
List as app&uble we0 ae+srrucYton permits(ie.eo,ouW.State.Variance,eta)
ft. ft. its.
3.Well Use(chechwell use). iZ SCREEN
Water Supply Well: FROM TO DL{6IECIR SLOT SIZE THICHMM MATERIAL
❑ 'Agricultural DA6 blic !11 E hC
(3Geothermal(Heating/Cooling Supply) esidential water Supply(single) % tL ter'
01ndustrial/Commemial ORcsidential Water Supply(shared) 1L GRODT
FROM TO MA EMPIACE6MTMErAODAAMOM
f 0 .on to to
Non-Water supply well:
OMmitoting ORecovery
Injecti6n We": R R
OAgai&rRechasge CGrondwaterRemediation 1ASANDAMAVELPAtB
FROM TO MATERIAL EMFLACEMZNr METHOD
OAgaif�a Storage a�Recovery05afin3y Barrierft.
OAWiferTent OStotmwaterDrainer
OExpe imeatal Technology OSubsidenm Control IL
OGeathe:mal(Closed hoop) OTsscer 2a DBII.LING LOG attack udttlas el eisate E
FROM TO DESCRIP[IOR eolor hZrdWM salYraet Mk OVID SkL etG
Mrco h rmal ftakgACooling Return) 130thcr(cKplain under#2I Remadm)
4.Date W f / 2 r Well(s)Completed.
Well Location.
1 Ste" 0
Facility/OwnerNamee h p FFaacilittyyp#(ifopplicable)
1ue�1 ft
hysical Addr.%Cey,andZip 2L REMAHBSNov
CMEdy Parcel IdentificationNo.(FIN) L
5L Lathttde,and Longitude in de�sea/�dsecoDds or decimal degrees: ... :",, :;;`i;'• .;r-,, ,
(if well field am laUlong is sumac an) 22.Certification;
4L?
. o �CL4 W CCYC)PL-1
Signanae of Certified well Coatraemr6 L( e weQ(s) emanent err OTemporas7 gy ngaorg*►f-M I hereby ocn*&Tilts weJl(.d was,Orr earswirs-cd is amordmrce
with 1 SA NCAC 02C.0100 or 13A NCAC(t2C.0200 Weft Conr&uction Standardr and Hut a
7.L this a repair to an existing well• t]Yes ONo copy of"record hat been provided to the well owner.
If fht>'it a repair,jig mtkumn wefl com&ucdon fig a and e>plaur the mare of the
repair order#21 remantrsedia,or an the bast of fhir form. 23.Site dlagram or addltiond well detour:
You may use the back of this page to provide additional well site details or well
>�Number of wets conshuded. conshuction details. You may also attach additional pages if neoeasery.
For mddpk figeefim or non wasarsapply we/b ONLY with tha ame cexme rrouaa,you can
Submit orre form. 24.Subn*W Imtractlam:
9.Total well depth below land smiace: (fL) 24a. For AD Wells: Submit this form within 30 days of completion of well
For multiple we&/ur a0 depdtr ffdf'iere&(ecw pie-3@200'asd 2®1W) construction to the following:
10.Static water keel below top of easing: �� (k) Division of Water Quality,htforn-don Places he Unk,
tfs�atsrkirl is above easing use"+^ 1617 Mail Service Center,Raleigh,NC 2709-1617
11.Borehole diameter. ) g(ia 246.For Inieetton Welts: In addition to sending 91e 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: i V \�E✓1�� construction to the following:
(ie.a%m mfary.cablq direct push;etc.)
Division of Water Qua1Hy,Undcrgiosmd Injection Contest Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mall Sersviex Cetsler Raielgh,NC 27699-1636
13a.Yield Wm)�—Method of test: 24c.For Water Suoab&Gm1hn,<t Webs: In addition to sending the fain to
i the addresses)above, also submit one1
copy of this form within 30 days of
136.Dh3afection type: Asno®t• \ completion of well construction to the county health department of the county
where constructed
Form OW-1 North Caw ion Depat4m t of Ewuormteat and NaturW Resources-Division of water Quality Revised Jan.2013
i
f