GW1-2021-06893_Well Construction - GW1_20210505

WELL CONSTRUCTION RECORD
For hrteunal Use ONLY:
Thu farm m be»ged.for single or multiple wells
1.Well Contractor In&nn%dtin:
1t WATM ZONES
Ronald E:` beter Jr.. FROM TO DEscRlprloN
WeilCa�torxmme •_ ti
2960-A n
NCWellContiaetorCetGGcationNumber MOUMCASING mukkassdweb p$I,iPip,Q
FROM 70 DIAMETM- 7ffiCKNFSS MATERIAL
Southeastern Pump St Well Service Inca _ - I la.
Company Name I6HN040RCASIPIGORTI7BINGfimetWriand dowel
FROM TO DL METW I MCKKM I MATERIAL
2.Well Canter don Permit A w IL is
Lid aD app&nble wag eonstructionperrnits(is.Cmsny,Stain.Voris V,em)
ft. ft. a.
3.Wall Use Use(eh well mar 17.SCPIZN
Water Supply Welh FROM TO DIAMEM SLO s= UUMOOM MATEttt w
❑Agricultural IbaicipaVPablicfL rt. j t
DGeothermai(Heating/Cooling Supply) (]Residential water Supply(single) ft. 1O
Din Commercial ❑Residential Water Supply(shared) 18 GROUT
FROM TO MATERIAL MAPI.ACEl11ENT METHOD&AMOTINT
Non-Water Supply Well:
DMm$oring IL fR
DItccovery
j-ft n Well: n tti
DAquif-Recharge DCramdwaterRcmediation RFRAMTO
1DIGRAVELPAt3 I MATERIAL I EMPLACEMENT METHOD
DS
DAquifer Storage and Recovery alinayBamer fL
DAgaifetTeet DStormwatcrl)ainage Iti
F1 DVerimental Technology DSubsidence Control
DGoothamsl(Closedhoop) DTracer IL IF
3&DRH,MGLOG atheladdmanl,Mat.if
FROM TO DESCRIPTION cnbr sanh wit IVDL grath SUM6 era
DCeothamal(H jng Retum) 130ther(cxplak mtda_ #21 Remarks) fL IL
" to
4.Date wdk(s)Completed:
ft.- f
5.Wen Imcation:
Facility/OwrKrNmme FacilityM#(ifapp5=blo)
ry b\/0 4,/V C- a?qsg ft. IL r
Physical Address,City.and Zip 2L BF.IIlAHStt y
-Asing Unit
�Y Pmcel2demifieabonNo.(PJIT) �;�i{3:,.civr € „t+011
SL Ladt ide sad Iro mitude is deppeea/ t wisecaads or dedmal deg rem 21 Certification:
(ifwellBe1d,arcsufficient)
uuff is
( �A /h 075
N 760 01 , 80 W
�/ of certilied well co�ee6or D4
6 Is(an)the weH(s): C3Famame or DTemporar7 py dgmg*w fam 1 hereby artily Ow'Me-&a(. vac(rrercl cacsbracard br acsnrdarwe
/✓// with 11ANCACO2C.01WorISANrACOZC.0200Wel<Con nStmdardsmudernea
7.Is this a repair to an esisting well- Dyes or copy cf thir record hen been p vvubdto the well owner.
if Bra is a►epair,fi0 art known well corutrvction information mid explanr the nave of the
repair under#21 renranbsechon or an the bock of thajorm 23.She diagram or addifloaai well details:
You may use the bank of this page to provide additional well site details or well
L Number of web constructed: canettmetion details. You may also attach additional pages if necessary.
For aadhplairyedionorro,}waarrmWlywellrONUwdh hesaae=vue8en,youcan
submit oneJbrm 24.Subndttd Instructions-
9.Total wall depth below land sarfaee: N. (f!.) 24a. For All Wells: Submit this farm within 30 days of completion,cf well
For rmrlliple weIIerat aDdeprhr ifdiffererd(mmrrple-3 r@200'ard 1®1W) conshuctlon to the following:
10.Static water level below top of casing: `O (�) Division of Water Quality lufornsttion Prvicesslog Unit,
w gain&use' 1617 Mall Service Center,Raleigh.
U nice level is above c +' NC 27699-16I7
11.Borehole diameter. , ' (in.) 24h.For Injection Welts: 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 comtroedan construction to the following
(Le.augery rotary,treble,direat push.etc.)
Division of Water QoaNty,Under iln—d'In*don Con"Program
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mall Ser, Cartier,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Saooh&Geodmnlal Wells:'In atldrtien to,.ding the form to
the sddteas(es)above, also submit one copy of this form within 30 days of
136 D63afixtlon type: AtDomrt: eompic-fion of well construction to the county health department of the county
where constructed.
Foan OW-1 North Camlim Deparunem of Eoraannew and Nanaal Resources—Division of Water Quality Revised Jeer 2013