GW1-2021-02770_Well Construction - GW1_20210805

WELL CONSTRUCTION RECORD
This form can be weed-for single or multiple wells For Jntemal Use ONLY:
1.Wen Coatrwotor Infor tnation:
Ronald E.°Keeter Jr.. la WATERZ0rM i
FROM TO I DFSCRIMON
Welt Contractor Name _ iti 1L I
2960-A fL tl:
NC Well Coubacmr Certification Number IS OMER CASING O&OrrasalOrwred wed OR L IlOMR
FROM TO DIAbtLTFE• THICR2rEtt TMAL
Southeastem Pump &Well Service Inc. _I Il _
Company Name
2.Well Coast (J�J 16�tIatli�CAQaJG OR iT1BIIt>G
V FROM TO DUdfUM THICKNM MATEMAL .
nution Permit I!: ft. R
List all applimbk weft mnstrwction prnnibr(is.Corerry,Smm.VarierrcR era)
ft: R Ea.
3.Wen Use(cbft*well me? 17.SCtt> N
Water Supply Well: FROM To DIA&MM i 6LOTSG� D UCIOYffit MATERIAL
OAgriculturai ❑Mu ' ' blic % It. 1 le
❑Geothermal(lieating/Cooling Supply) ideatial water Supply(single) tt. r to
❑IndustrinVCommercial OResidealiai Water Supply(shared) 11�17T
FROM TO MMEBU t3 L EMPLACEME(tT LWHOD AMOUNT
(3krigation © fL
Non-water Sup*Well:
OMmrtoting OR,—„-, R R
Well: ft. R
OAguif r Recharge OCuvondwater Remedistion 1A SANDAMAVEL PACE
FROM TO I MATERIAL EMP!ACIIYIEIrr M1CfHOD
OAquifer&mgeeodRecovery OSatinityBarrier & &
OAgoiferTat OStamwaterIhainage R
OF�mimmtal Technology OSubsidenee Control ft
OGcothamal Closed 7ADRILLiNGLOG afEse;addlannaleltsetsP
( Loop) OTrawrQ FROM To DZ0CRWTION color. .dfhaiet PM rain sulk ate
Micatheamal(l3 • - Retma) 130thcr(cKplain under021 Remadm) n &
tf:
4.Date Wetl(s)Completed �: iG
.Weil Locpjiop: ' P ,�y rL IL M R
POFecw7' / Name ^ FacilityII�1(ifepplleabb)
tt
ft. ft.
hrimi Addm!M City,suet Zip 2L HEMABHH 1 1
essin9 Ufa
�r Pameliaemsca6anNo.(FII� 1�#01�' gmr- old
5b.Latitude and ImWitsde in deg ws/minuta/secoads ordecimal deg ees: 22. cation:
(if well field,one leuloog is sU[B )
W r-u
Signature,of eerdw Well Camhaero,
6 la(are)the weals} Pemtneat or OTemporary BY s+8-9 d-f-M I hereby 994*Hsi the voft was(wcm)cacrtrucred in accnrdmoce
with 114 NCAC 02C.0100 or 15A NGlC!02C.02W Well Conripuction Sraadardt and that a
7.L this a repair to an wishing well- OYes or o copy wf thtr mcmd her been prnvukd ro the wen owmr.
Ifthb @ arrpai,fi!<avt6rown well rnnaavctanv¢ormation mrd esplavr thR rwmre of du
►epmr wider#21 remarb section or or the bmat of tWform 23.Site diagram or additional well details:
r You may use the back of tl>m page to provide additional well site details or well
&Number of weft consh•rsoted: 1 construction details. You may also-sch additional pages if neceemuy.
Formakilik nyeetim orrorrwaerrsupplywensONLYwith the same eawrbuaeen,you can
submdonsform. 24 SubmkW IDshvcfiome
9.Total well depth below land eurfaee: 'V L/ . (1L) 24e. For AD Wens: Submit this form within 30 days of completion of well
For nuaiple wet&lhr an depths ifdiffn4nt(-ample-3@200rr'and 2®1M) construction to the following:
10.Static water level below top of easgng: V M) Division of water Qua t lifformation Processing Unit,
4'*w adrr level is above ear ft use a w � 1617 Mail Service Ceder,Raleigh,NC 27699-1617
11.Borehole diameter. t (in) 24ls For Iniwxtlon 3ye1tx 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.Wee construction method: 1 lJ 11 LJ l/�� construction to the following:
(La.mwget:rotary,eabK directpulk etc.) - I
Division of Wetter Qua t!,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 NUB So 9 Coder,Raleigh,NC 276WI636 -
13a.Yield(gpm) Method of test 24e.For Water Sunoh do Rotas W Wells: In addition to sending the form to
the address(es)above; also submit one copy of this form within 30 days of
13b.Dgdnfeetion type: Ate; completion of well construction to the county health d9m1mcat of the county
where constructed. I'
Form GW-1 North Carob Department of Environmext and Natural Resources—Division of Water Quality Revised Jet 2013
Aug o� Zoti1