GW1-2021-06902_Well Construction - GW1_20210505

LL CONSTRUCTION RECORD r Fotlaftmsl Use ONLY:
This form caw be wed-for single or multiple wells Gri
1.Well Contractor Infmwnation:
_ iA
Ronald E:Keeter.Jr.. l 1 14.wAZEsZOM
"tom TO I DEscilrrloN
Wallt:ohhadaxeme _ L ft. ii � •
r
29saA .M tt
NC WeU Contactor CertiHczboaNumber is OUZES CA.�iG sr�Y4eapd wed ORLiNPQ
FROM TO DI SMM• TffiCft1 M MATO AL
Southeastern Pump &Well Service Inc. ra.
Company Name 16 ECUR TUIMM elua.d
FRAMTo DUMErW TMCKNM MATHd"
2.Well Construction Peemit#s �� �43 tt
Lid aff applicobk well mnstrrrctton pemrtis(is.Cowry,Stoa,VariatteR etch
�tlL R m.
3.Well Use(ehecfcwe0 mar 17 SCREEN
Water Supply Well: FROM TO DJA&W= SLOT SIZE I TMf!k7QM I MATF.RLAL
❑Agricultural paVpab&c n -M IL ' >d
OGeothermal(Heating/Cooling Supply) ELQj&mfiaj WsW Supply(Slagle) ft. ft. 1d
OLadushiWCommeeaial OResidmtial Water Supply(shared) 19 GROM
FROM TO MATEB(AL EMFLAQf1MEttT MUBOD&AMOUNT
akri m R'
Non-Water Supply Well:
R ft
OMaudonng OR—very
Injection W . tt ft
OAgmif-Rcaharge OCxoandwalwRemodistion 1 1%SADIDOGBAVELPACSIffamfinaki
OAquifetStorageeadReoavay OSalinityBsa FROM TO MATERL L XROI ACI7Y M METHOD
Barrier � �
OAquiferTest OStamwaterDrsinsge `
OFape immtal Technology OSubsideaw Control
❑GeoUresmal(ClaedLoop) OTraeer Z0.DRIILIIiGLOG attaeisrll/fuanlsiestai
FROM TO D ON(to saivraea -sY aft:
OGt.othermd(H ' RRCtam) OOther( lain undcr#21 Remark) C�L
ft-
4.Date Well ts)Completed: c )� ' 4 I o� R C
5.Well IA on:
fL
Facility/\\Owa��-Name /t �/ FacilttyMffi(if`ep
me _pHcable) IL fL
�7A,Jlress, ,and Pe�,�Y X o 2
021
2L BEllfAlrt$B
lu�auil t �E?%f1 CN �sSlCe7Unit
Cant Parcel Ida tioallo.(PII� 4'Y i�v::; .Oi 1
SL Lad ude and Longitude is degrsealmhrutes/aecoads or dadm d depees: 2L Cerdecatloo:
(ifwell one hViong is s�ciea)
'V� . 0 . -t . l5vl W
of is aufied Wet Cow ZCW D
6.Is(am)the we9(sp ermanent or OTemporary BY,www this f-M I hereby—f6 A&Nre welf(s)wan(were)cautrachd ii,aavrdmas
with 15r NClC MC.V1W or 15d NrAC 02C.02W weft e:onstrvetion Standards and dot a
7.Is this a repair to an e33sdn we0: OYes or o copy of ehtr record has been pwkbd to the waft owner.
If ties is a repair,jw.aabwwn weft mmtraction firfaaaation and erplairr the nave of the
repmr corder 921 remarksstaboe or an the back of thirfimn. 23.Site diagram or additlooal well details:
You may use the back of This page to provide additional well site details or well
&Number of wets eomtrneted: e:onshuctim details. You may also attach additional pages if necessary.
Formu►fipk nyeetton or roxwatnmT*we11sONLYwith the nose eaubreaea,you eau
srt6sadorrfana 24.Submittal ImtrueHaos:
9.Toed well depth below bond surface: (ft,) 24s. For All Wells: Submit this form within 30 days of completion of well
For=Mple wells lest afl depths ifdonM(armnpb 0V'aW 2(WM construction to the following:
10.Stolle water level beI top of easing: (ft) Dwwb w of Water 1 ,7nformutton Processing unk
(f tvaorr level is above carfrr&use"+ 1617 Mal SavW Cmnter,Raleigh,NC 27699-1617
--1
11.Boeeitok diameoer. (in.) 246.For IntecNon Wells In addition to Bending the form to the address in 24e
�/� above, also submit.a copy of this form within 30 days of eompktion of well
1L m Well coemwilms nretbod: \ constrution to the following•.
(Le.auger,rotary.cable,direct push,Btu.)
Dhdston of Water QuaHq,Underground Injection Control Program,
13.FOR WATER SMTLY WELTS ONLY: 1636 Mail Service Center,Raleigh,NC 2769OL1636
132.Yield(gpm) Me15od of test: 24e.Fer Wster Sono de G elm p 1 Wells: Tn addition to oendnsg thef nor to
the address(es)above, also submit one copy of this form within 30 days of
13b.Dbdnfseflan Vim. ` \ Arno®:: compkbon of well oeustiuctim to the county health depattment of the county
where constroctcd.
Form GW-1 Nmth Cuohm Depwbmnd of Favaeanmt end NaturW Resources—Division of Watcr Quality Revised Jau.2013