GW1-2021-06898_Well Construction - GW1_20210505

ORD Forinsa W Use ONLY:
le wells
eter Jr. 14.WAMZOM
FRAM TO DFSCRMnON
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CWellCo orCati_HcabonNumber 15OUTF..QCAMM reiN aced web ORIII�Eit
FROM TO DIAMErlR- THICKti)fSS MATERLIL
SoutheastemPump&Well Service Inc.' fL n. 4 �.
Company Name 16 DOM CA87Tl('OR TOBIIVG closed
i FROM TO DL4bCtrEC •IIUCKNESS MATMUAL
2.Well Coadr uedon Permit#- fr. ft �
List all appluaabk wa0 evasbvetion pnmfts(is.Coargy,Stanr,irorfasscs,tta) IL M m.
3.Wen Use(ebeehweil use).. 17.SC=t+N
Water&Apply Well: FRAM TO I DIAM E8 I SLOT SM I TH[CKKM ITFdtIAt
OAgriouriurat OMunicipal/Pob&c G *. !t. L
C3GWthama1{Hefin8lCooling Sup*) OttcaWntial Wets ftWtf(single)
ClhsdastrsaVCoenmetcigl OResid--U Wt.Supply(shared) FROM 70 11fA blECHODRAaROiffrf
Non-Water Sup*Well: � it:
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hkiecdon Well: % ft.
OAgoiferRooharge 13Qnxmdwat=Rmtodialiton M&4KDAMAVELPACK
OAguifer S-"d-sW R000vary Mnlinity 13aaicr FROK TO_ mATER[AL EIDrrt.ACE Mff METHOD
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OExpaimentai Technology CCSubsidenc-e Control
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'Sb.Latitude and Irrrgittde in degrees/ erJseroada or decimal depsea: 22.Certi@caftim. y. 'V
ifwell bald,ace sufficient)
Sigasbna of Ccrtifrod we11 Cmmadmr
6.Is(ara)fire wen(s}s aysaaeut or ❑Temparart By, *W f&-^I h"rby xr#5'MWLdM,reIIls}war(rare}corsrdsxad in oavrAmm
with 114 ACAC 02C.01W or 15A NCAC 02C.0200 Weir C*m&uc8onStaadardr and drat a
7.Is this arepair to an existing well- Oyes or QNo copy�sMs rramcihas bear pnovfdrdta sbewaRowner.
If drft fro rrpafr,fill autircoaa weUraratrvetlon frrformatba and esplafa the raraue of the
repair amkr F21 rznrarkssechm or m the boat offimform 23.Site dlWam or additional well dens:
kYou may use the back of this gage to provide additional well site details or wcn
&Number of wells comctrueted: oeostmotion details. You may also attach additional psges if necessary.
FormafNpk irVertim or aon wattr.snpplywelkONLYwdh ft smae;Wu— eIIaa,you emr
submit one form. 24.Submlttal Imtruedom-
9.TaM weld depth below bind emiaee: (R.} 24a. For All Wells: Submit this fam within 30 days of completion of well
Fornmufpis,.eti hrattdEpBsjdffi-W(aa*,-3W00'ttand2WW) consftedon to the following:
10.Sbdk water levej below top efeasingi_ l �,) Dividon of water Qudityr Woetnadien PnWeajme Unit,
.{fwaferkeel it above casfng use"+1 1617 AUR Service Ceatsr,Raleigh,NC 276WI617
IL Borehole diameter:c� (in.} 24b.For Injection Wei- la addition to sanding the foffi to the address in 24a
M wen coostrucilan me N tod: above,also submit f s copy this form within 30 days of completion of wallwalloonstAndioa to e following.
(La mqm routy,eab1%daeetp nk dn.) _
Division of water QM ft,underground TjM*don Goub'd Pt"F=4
M FOR WATER SUPPLY VM IS ONLY: 1636 M4 So eke Center,Raleigh,NC 276WI6%
13a.Yidd ft" r1)C) Method of teat: 24c.Far Wader-S;pRjt do Gspdrereeol Wdh- ht additim tosdsdmyg t)te fo-m to
the addmaKes)above, also submit one copy of this form within 30 days of
13b.Dbdafes Lion types Amount:I CA Cj awplation of wet)construction to the county health dalwtmemt of the county
whae mustmetcd.
Foan(FW 1 Nw&CawhoaDepsmrrmofE=omse=aad11aurs)Resoums-Di WouofWatarQunlity Revised Im 2013
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