GW1-2021-06899_Well Construction - GW1_20210505

R
WELL_CONSTUMON RECORD Fcrtnb=el Use ONLY*
This farm cp:be ud..fer single or multiple wells
1�Well Contractor Iofotmad6n:
Ronald E:`Kseter Jr.. " 1 nm _I ort>_s DESCRiFriON
WaftCatmtaetaName tL f
2960-A IL IL I
NC Well Couhaetor Cmtiflcation Number " M OUTER CASING Isaltbead wets ORLIl�R
FROM TO DiAs�rElt TBICYN&4S MATERIAL
Southeastern Pump&Well Service Inc. m Few
Company Name ! r / igR yM� TC DLiMLI1X TIQCK[ 88 MAT28IAL` '
2.WrO CoDetriuedon Permit#;. M IL t°
Li#aII le we0 aonsds+edfanpermOs(is.Comnjv�ariaM%snr.J
°1rp r it & is
3.Well Use(ebeck well me): 17.SCRE[+.N
Wader Suppbr Well: FROM TO f DIAMETER ISLOT SM TIII-MM MATERIAL
OAgricnfhusl TaTPabhc
lic—&-area of-t-f/cooling Supply) mfidudiai Watt Sapply{single} R• !L to
OladuakiaVt ommaciai Oftcaideatial Water Supply(shared)
FROM TO MATERIAL EMKACEMEXf METHOD k AMOUNT
❑ et2m tL 1L
Non-Water Soppy Well: f ft.
. OManiWning OR'cc°very
Injection W . n tL
OAquif-Recharge ❑Grcandwateritemediabion 11UNDILDIAVELPACK(if apolleable)
O CBadRdfOVQy OSalinuyBaaier I1Vft- i
FROM TO r MATERIAL EMPI.ACIMMICMXTHOD
MquifbrT�5 OStarmwaterDninage
ft. IL
OEVe immtai Technology OSubsidalce Control
2RDBYLLINGLOG atsssiaidfaasrslsia.lalt
OGoothermal(Closed Loop) OTraeer FROM TO ON canon AdYraetM4SUIL arc
OGecthdemed(H Rdtttm) 013tltc ( htmmdcr#2IRdarerim) ') IL iL 11 la 1
ox-tt m ,
4.Dote.Wdl(s)Completed: 9� �.
�.1 5aac
Will Location- tt tL
Facility/OwnerName Fsa M#(ifepplicable) tL
licalAdddrtaja City,sad :p' 2LHEt+lAB88
Canty PmrnatIdeatifncatiauNo.(PII� I6:vili;-.t ° � C* ^;Oil
5L Latitude end Longitude In degreealmbruteslseconds or deetmd deereea 22.Cerdlicati ;
(ifwell roK one lstlla�ng•is suffrcima)
erIf
1D.. N � �_.._R' of catssa well coahazCor D
i
6.la(are)the wee(sk ertmanent or OTemporary gy,tom darfam I Eby orrf*that;the weII(5J war(ware)c+ws:awa4d in a=rdmse
with 1St1V ACO2C.01Wor15ANClCO2C.0200WeCanrerachiaaSmadardrandthea
7.Is this a repair to an existing well: Mes or copy gtthis rscond her been povtdrdta the wail awmr.
repair
is der#21 en orrtknawn malt on SW bofoa arjannarion and asplanr the rmaore ofthe 23.Slte or additlomi well details:
repab carder S2I rcmarkrs�adane or on dhr bang af�ehi:ferm. dFagrem
You may use the back of this page to provide additional well site details or well
8 Number of wells constructed: comtmctioe details. You may also attach additional pages if necessary.
Formuf*kWedkmorna.-wahn,m ptywelkONLYwt**0mmeaertra as yar:can 24 Submittal lmtloetiaosw
submit ons front
9 Total wail depth below land surfed �� (fL) 24e. For Aii Wells: Submit this form within 30 days of completion of won
Far rrarUipte wage ticr aD ddydrs ijd srera(ermnpls 3( 200'ard 1®IOd7 construction to the following.
10.Sty water kvd below tap of casing: (It) Divhiau of Water Qaalkyrleformattou Ptvicesdng UNt,
fv,aisr kvel iwabovw curing use"+^ 1617 Mail Satvics Canter,Raleigh.NC 276"-1617
11.Borehole dlanater. F:5 I i('� (I..) 24L Far Infection Weer. In addition to salting!hc fdract t4 the address in 240
` ( above,she submit-a copy of this form within 30 days of completion of well
12.Well construction me@rod; ` construction to the fonawing
(L-auger,may.Gaw daect prak etc-) Dtvialon of water Lnjecdou Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 NUN Servies Cernber,Rabe NC 27M-16%
13n.Yield(gpun) ,_ Method of fast: 24e.For Water'SuDy L ore{ (Weill In,addition to sending the form to
\ /-►' the address(es)above; she submit one copy of this form within 30 days of
13h Dhhofecdon type:.l�_ A minute *l s completion of well construction to the county health department of the county
where coustnoctrA
Form ow-1 NathCwohnaDepmun atofFsvvommatandNebelResources-DmuonofWaterQus�sty Revised Jan.2013