GW1-2021-02712_Well Construction - GW1_20210805

WELL CONSTRUCTION RECORD For lnternal Use ONLY:
This form can be used-for single or muhiple wells
I.Well Contractor Iofoemad6n:
Ronald E:Keeter Jr. 14.WATERZ01M
FROM TO DE6CRIFfION
well CdLow"Nam it R
Z9saA rt R
NC Well Cotoactor Certification Number 13 OUTER CASING gar sub-aseW weL OR LAER at
Sou#heffi I[RESB astem Pump&Well ServicROM TO DIAMEM MpTEPIAL
e Inc.lnc. � r�_ N J .
Company Name lt< G.�IG ORTORDV[� el�a
i FROM TO DiAME IAA Tmc!g SS MATIIUAL .
2.Well Construction Permit#.L,J � r 1 ld h, m r,
Lid all applicable well aonsDnetionpernntts(is.Comnq m,Varionct era)
tti R. ns
3.Well Use(cheep well user 17.StREEN
Water Supply Well: FROM TO DIAMEfm SLOTSIZE TBICXN= MATERIAL
❑Agricultural ❑Mu btic 41bn • '-L IL f Is. �ja �r
❑Goothamai(Heating/Cooling Supply) • idential Water Supply(single) ft it is
❑ladustrialtCammrneial ❑Residential Water Supply(*hated) 1&GROUT
akrigation FROM TO MATERIAL EMPLACF11t1r,NT NWHOD&AMOUNT
Non-water Suppty Well:
❑Monitoring 11Ra• cry R flt,
Injection Well: % tt
❑AgniferRechasp, ❑GroandwatcrRanediation MSAND0RAVELPACH
❑Aquifer Storage and Recovery 0Sa64 Bar ricr FROM TO MATERIAL EMPLACEA1P�fI MEtHOD
tL
OAquiferTest ❑StormwaterIhainage
IL tL
❑Experimental Technology OSubsidenx Control
❑Geothr=mel Cioed 2RDRUJINGLOG on"additloadAestalr
( Loop) OTracQ FROM TO DEBCRIpTION mbr ronhark sa a�
OGeothamal(A Remus) 130thea( lainander#21Rematim) &
241
4.Date Well(s)Completed: .tt
S.will Location: IL IL
Facility/Owner,Nspie -i1i1YlD#(ifappfi=bje) tt fG f
2
Address,City,
and Zip 2L REMARKS
Cry ParcelIde ionNo.(pjN)
Sk Latitude noel Longitude in degeees/minades/seconda or decimal degrees: 0
if well field, a sufficient) 22.CertMontlon-
)
ngnatrae of Cartifiod Weil Coaeaeler Date '
&Is(are)the wee(sr a maneut or OTemporary
By signing thirfanb I herby wn*that the weft(,)was(were)corutnt ,d in accordmr v
—� with 114 NCAC 02C.01W or 15A NClC 02C.0200 Weft Coar&ueeon Standardr turd that a
7.Is this a repair to an existing well: ❑Yes or O rnpy q Mir record har been provided to the wen owner.
lfthir le a repay,,fltl mtkwwn wellcvnstrvctioa irformatkn and cTkdr the name ajrdw
►epair wider 021 remmlvsectiw or on the bast:gfthisform° 21 Site diagram or additiooai well deWh:
` You may we the back of this page to provide additional well site details or well
&Number of wd b constructed: l construction details. You may also attach additional pages if necessary.
Formuthplir injection or ron wamr supply wells ONLY with the sure eaes6swdon,you can
24.Submittal Instrocfiaos:
9 Total well depth below land surface: (g,) 242. For Ail Wells: Submit this form within 30 days of completion of well
For rrahiplr weUr lid all depda ifdforew(it-Wis-3(a1200r•(onndd 2@1W) construction to the following:
10.Static water keel below top of casing: V (L) Divhioo of Water Nudity,Inf..Hon Proceeaing Unit,
{(voter level is above cavft usr 11 " j� 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (lo.) 24b.For Iniecton Mk-- la 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.Welleoustroction merlons: 1 �1w1��1 X ' wnatruction to the ED11 in
(Le.eum rainy,eable,dw—tpu sk etas
13.FOR WATER SUPPLY WELTS ONLY: Division� Quality,Underground h,NC
W16ontrA Program,
Raleigh,NC 27699-1636
V Mefhod of test- 24e.For Water Suook&Gmdternial Wells: In addition to sending the form to
13sLYIeld(gim) 5
the address(es)above; also submit one.copy of this f within 30 days of
13b6 Disinfection type:_00 Amount: completion of well construction to the tut of the countywhere censttnated_ '� ryQ
Form GW-1 North Carolina Department ofF.avirorment and Natural Resources-Division of Water Quality, p U G O 2 �O L e Revised Jam 2013
NC OE0IDWR
central Office