GW1-2021-06901_Well Construction - GW1_20210505

WELL CONSTRUCTION RECORD ForJnWW Use ONLY:
This farm cell be uud•forsiogle oripultiple wells
L Well CoubudorInformatien:
14.WATMZOMM
Ronald'E:!Keeter Jr.. FROM TO
R
DrEcaaII'Ttoit
We1lCohtaetorNeme '> e. n-
29saA R
NC WenConhactaCettificotionNumbor MOAIZRCASING ra14laaadweL ORL1rIP8
FROM TO DIAMETER'- 7HICIQiE36 MATERIAL
Southeastern Pump Sr Well Service Inc. ;ti R_
Company Name r�q I I 16I1Ui1 CA.�iGO8TURM fimodwreasi d6.a
PROM TO DIAb1 M rffiCK MATEM AL
L Well Conrtniction Perrok r fL R 4L -
List all,applicable ws0 aurntruction permits(is.Comuy,Sam,Varienes,era)
R R is.
3.Well Use(checkwell me). 17 SCRERN
Water Supply Wen: FROM To DLIMMIM. IsLor aver Tllrcxivss
OAgricullural p b&c R to
❑Geothermal(Heating/Cooling Supply) Arrest A r Supply(single) if [t to
❑lndushial/Commeeoial OReaidcatial Water Supply(shored) 18 GODT
Ohri ation QEMENl'
FROM TO MATERNL teMFLA METHOD&AMOUNT
R R
Non-Water Supply Well: R R
OMmrtaring ORecovay
Injectim Well. R R
0AquiferRechatge OCaoandwataRemediation 19LSANDH:BAVELPACB
EMPLACEMENT MItTHOD
DAgoifer Storage and Recovery OSalinily Bsaic FROM Efl,
TO MATERIAL
R �, ,/.
OAquiferTeat OStormwatorIhainage n 1
OFxperimmtal Technology OSubeidetxe Control 20,DBILLIl�TGLOG attereiadedtorat eCteelylr
OGeathamai(Closed Loop) Mracer FROM TO DESCREMON mbr, nuflat str eon
OGmthamal9 Retum) QOlher( Lain under#21 Remarks) ft. C`(
�a R
a Date Wells)Completed: .
R R
Wee Lora R R
R
Facility/Owner Name j R FeeibtyM#(ifeppH=bb) G SW
� E,-
CPl�lr 2LHFATAM
COUDLy Parcel Idmlifieafim No. DWIF"section
5b.Latitude and Iarrghude in deg walmim teoZi -ond■or decimal dgpves: 2Z Ca-Mcadion:
well fie am a suffrcient)
N �� I .'��-f W I
DfA
ti.L(are)the wer(sr ¢Pt�nent or OTemporary ' of Ceceitied oven Comraemr
BY dgnirr8 thirfarrrr 1 hereby mn*dW dw weII(d was(were)constructed by accordwor
with 114 AVAC 02C.01W or 13A NCAC Q2C.0200 WiOCanrtnxRon Sh dardr and that a
7.L this a repair to an existing wen: Dyes or o copy cf d&record has,been provided io the well owner. '
If tilt is a report,fell avtArrown well ains6vcfion i#br7na bn acid espbrbt the nacre ofihe
repay corder#21 remarkrseetiah or err the boat of thisfonm 23.Ske diagram or additional well deters:
You may use the back of this page to provide additional well site details or well
L Number of wells conshmaed: construction details. You may also atlarh additional pages if necessary.
Formdfipk agection or non wamrsupply welts ONLYwOh At sae earasbra8en,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below laud smfnee: (fL) 14a. For AD Wells: Submit this form within 30 days of completion of well
For rmaltiple wells her all depths tf different(cam»pls-3@200'mad 3 jW) construction to the following:
10.3mtic water leash below top of cnsiing: 1 m) Division of water Qtta*,Inl'ormadon Proceaioe Unit,
{jwatrr level ie about carbi&erne"+1 1617 Mail Service Center,Rokigh,NC 17699-1617
11.Borehole diameter. (in.) 24L For Iniecdoa Wells: In addition to sending the form to the address in 24a
n above,also'snbmit.a copy of this farm within 30 days of completion of well
12.Well construction method: ��l [ n I construction to the following:
(i e.auger,rotary,eeb1%d—push,etc.)
Dlvislon of Water Qoarty,Undergrouud Lo*dan Coated Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mafl Service Center,RaidgN NC 27699-1636
13a.Yield(gpm) L Method of test: 24c.For Water Suonh&.^,ate..—�1 We tin: 7n addition to sending the farm to
the addrees(es)above, shto submit sae copy of this form within 30 days of
13b.Dbdnfeetion type: Ate. completion of will ooashudicu to the county'health department of the county
where constructed
FormGW-1 NcuthCazo DVartnentoEEr,bonmemsodNaturalRaaaees-DivisioaofWaterQoallay Revised Jan.2013