GW1-2021-06887_Well Construction - GW1_20210505

'WELL CONSTRUCTION RECORD
010� 7 hit farm can be used for single ormultiple wells
1.won C tot1 Forinlems!Use ONLY:
�reatton: '
Ronald E:'KeeterJr..
WellConpN� ._ itwAszotiFs
FROM TO D
z9saA >L tP7TON IL
MC W-II Co Ceti[ fL 2
e at;oaNemmber
Southeastern pump110
Well S OR
c er�
Service Inc. �tO1i TO D1A6 e.
�1'lq � k fL TffiCKNLSa MATS.
2.We'11 Comtt+aiton Peempt#; !6CA, GR
List aD 4PPlirnbts>oeD eso FROM TO .
3•WeU ilae r+ranctioaD�+sh(tt.Co:ouy,Sarin,troriaa�r ft D �pm T1UCIt> g MATS
(dsecicwen me):
waver Soppy wets: IL ' m
❑Agdcullurat 1%sclil►.Fpl
��,� 1 to arna
❑Geothermal(Herb-alcoo' � PaUPabhe , to THIe O MaTat:t�L
❑ladushieVCommc,,W �PP13') ietattial Water Supply(smPk) M &
LIL❑
Mcsidentisl Water Supply°PP1Y(shrtreei) 11 GRODT
N SnPP�!weU: FROM TO 1dA
7�
1AIMttoo W QReao tL �� f i D&,1Mo
very m flr
OAVifer
❑ �' � ❑Gro:tadwatwRemodiatiaa IL
N St�eeaml 1A PELPACK
❑ FROM TO
❑Aquifer Tent q�at�>� � srAJERJgL C>�T
> LaoD
❑F�aimeatal Technology ❑Shxm Gooth ❑Stdraidenne Conhol
❑ ermal(Clave d op) ffi L
❑Geotham'd OT=ccr 24LDBII.iINGLOG�
Rom) UMCE( htin mrder#21 Remratlea) R r0 fL DEscR>pnext.n sdYtetle
4.Date Wdl(z)Completed: ,:. ate:
s.win
+ IL fG
L. m
Facility/ Nmne � h r
i FecilrtyllTq( a licabb) fL
ft
zealAddeatiCuy,andZip
fftL
Coemty
2L 8E11lAZ%g
Latitude Pmcel rtianNo.(p1N)
ifwoll bald klar{g seeorals or deelmap de' �6 a Gi l'.,.a i?Qn i roce e
n22.C-Iftmfloa:
N
,6:'Is(apt)the wel!(sr � --��W t `
t m' ❑Temporary of— won Cosh l 1
7.L thb a repair to an By
or
ith
Date 1
lfthbtsarrpalr,jr�art esisWaBwetL• ayes. ri w1 .O/OIDo�r1fluered(sJvarllrcrelcasrbvchdin
1eP�eerder821 brow�twelJrnmtryedoa gmaoioaa►d C0PY41fthirncWd '14CACMC.021mryDCa'tea ssaekeri or oa du beat 9Pf61rfriim explayj the suave of du lxa'f P>�ded to the 1p,11awatr.e - =&u"'0a Standards end thu a
&Number of we& 23.Site d!agrmn or glMttisnd wed!
You' h+mi m71p' A"13,F' ONLYwi�Ar As �� coasts a oa4 d use am,��a�`o� ,additimal wen site daaila or well
manaseaffetr adffitional
9 TOW wnp de 24.Submittal Pegs if aecesaary
ForneWI weDr laY�1�land surface:
�Fs r lrr s st(esratp/e--WV,my � (R) 24 L Submit this'r 30 of
within 10.Static water 1evs1 blow top of co on to the followi W da3, Wmpktiem of well
UwatsrlerrlircLnvrc �° �� (n)
mom&arse'+ Dlvwoo ofwater
11.BCs ehok dpantefer: "�, 107 Man S rvk, ::!Von Pn�pa U ft,
�) 24b�For h'NC 276MI617
(ia--dd.Wen c 1
above;also a, y a a to sm�8 the foam to phe adds in 24a
c4mtraction to the fallo�wmgof this farm witttio 30 days of oomph tion of well
13.FOR WATER SUPPLY
R'ELLS ONLY: Dlv6h0ft of Water Qo t
13a.Yldd(gpm) tl��rllrRW6 InJJecHem Coutrop P"n.w,
1636 Ma9
4 11 dbod of teat: Ceutber,Rah,NC 27691y636
13h.DidnfaBoa type: 6 th4c.F, a. to jL
�..
Q( )above, also : la add tiQn toser! ffie Amo�t; comPWOR of well°autruetiqu to the copy of this form within 30 e
ays of
Form GW_1 whe m eoashaeled COU"tY hcalffi department of the eamty
Nrnth�O�DeP®aemnt ofFnviranmem end Natmal Ramaers_
Divi,iaa of Water Quality
( Revaed jam 2013