GW1-2021-06905_Well Construction - GW1_20210505

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This farm can be u sed.for single ortpultiple wells
1.Well ComractorIntbAnsilon:
-Ro a-Id.-E:jeeter Jr.. 14.WATE WM—M i
FROM TO DrSCRwHoR
Well CdidiaeFa<N®e •- ti tL �
2960-A M (L
' NC WellCornaetacCertifte�onNumber 15OUJ$tGSa�1G radit•aadwed ORLII��
FROM TO D1A6rEll7t• THICKNZ9B MATNUAL
Southeastern Pump &Well Service Inca + �.
company xame -^ ><i;.n�n�e ce.�lG oamun� - eso..a
�,�''�� FROM TO S numu TFIICRNrBS MATIMM"
2.Well Cunetrwilon Pwmit#:,--kj _ 1 R tL Is.
Li4 all applicable spell amavucrtonpanmfes(it.Cosmy.SM,Yariamces ow
3.Well Use(Cheek well me). 17.SCI&
Water Supply well: FRM I To DJAMMMA star sm irwm s I uIT"flif.
OAgticultatal btic 1`4
OCkothermal m-tin8��g Supply) @Water Supply(single) ff ft to
l]htduattieVCM+ »ial MUsideatial Water Supply(shared) 18 GREW
FROM TO I MATP.RUL EMPIdr$►tENi hMMD&AMOIINr
Ohfl .m O O
Nos-water supply well:
OMon$oring OR—vory tL &
. tc tL
OAquiferReoharge OGtoondwetwRemediation 19lSANID�C$AVELPACB
OAquifer Storage and Reoovety OSaliodyBaaier FRost To atnmRlAL 15fYiPLAC11YD3tYf
O ft R
OAquiferTest OStormwaterDrainage
OFXperimemtal Technology OSubsidenee Control tL IL
20.DRTLLIlPGLOG attaeiaiama..l,Yabr
OGeothamad(Clued Loop) OTnmw FROM TO DEscR>ptlotu obsrr hardness,saim"Ar wm yda-sus,eta
OGeothamal W ' Retam) E30&cr(csplain tmder#2I Rrmarim) R n
n' tt 4.Dgte Weli(s)Completed: �v�. �. . ... .. _ ..
+.Well Location: (t iL
12
Facility/OwnerNeme g 1Dq(if�y=,lql ''
a bty s.e
bysical Address,City,and ' 1
e R R � r 1
2L REAUM 1
".� ='C'.^cec--slriJ. )ill
County Parcal IdemfxaionNo.(PM
5L lAdItude and Iorghude in degreea/mimda/aeconds or decimal degrees: 22.C
(if well field am la llong is suffiaiers)
ore of Catif ed Well Chador Data
�-' 6.L(are)the wei(sx nmamemt or . OTemporary
By siV.T dmfomr 1 b by xn*dhat;da wefto woo(here!mv&.hd lei acsurdarme
with IliA ACO2C.0100or13dNCfClt2C.0200WeRCorowgionSwmbnisandBnta
7.Is tdds a repair to an existing weM Oyes or o copy of this record has beam provided to the well owmr.
Ifdh&trarepab'f ff. atbmwa well eonm vetfon irformatnn and espLrfir the nave of the
repair radar 021 remoskrsecdon or on do bock of thisfomc 23.She diagram or addhdaeral well detailh:
You may use the back of this page tc provide additional well site details or well
L Number of welt eorishmded: construction details. You may abo attach additional pages if necessary.
Formnldplr ngecdon or non wabrsvpply wells ONLY with the same ea sso yodow,you am
avbm it omfirm 24.Submittal Instruedoom
9.Total well depth below land surface: (fL) 24a. For Ai Wells: Submit this form within 30 days of completion of well
For—hipte weQr lirt all depdn rjdip—st(aammpb-3WOO'and l®100) Construction to the followhw
M Static water level bellow top of easing: M) Divhion of water Qaalhy,.Infornrdien Pn—uing Un
tfwahr level it above earft rue +"l) 1617 Maff Service Carrier,Rah ftk NC 27699-1617
11.Borehole diameter. (ia) 24L For lubcdan Weft In addition to sending the fog to the address in 14a
above,also sabmit.a copy of this form within 30 days of completion of well
12.well construcdon method: ` ��C l e construction to the following:
(ie.cagey .rotary.cable,&actprak eta)
Divbion of Wider Qmlity,undcrgto®d In*dun coww Pru rams
13.FOR WATER SUPPLY WELLS ONLY: , e ' 1636 Mai Service Caster,RaleW NC 27699-106
13a.YIeM(gym) Method oftext: W 24c.F��smr 9n�de(�d�e i 1 Wes: In addition to scalding the fam to
the address(es)above6 also submit one copy of this form within 30 days of
13L Didmf Won type: Amomw. completion of well oonatradim to the oamty,health department of the caaaty
whale constructed.
'i
Fours OW-1 NorthCmolina Dezrbnma ofEunronment and Natural Resources-Divisioaof Water Qua l$y, Revised Yom 2013
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