GW1-2021-03404_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD Farintemal Use ONLY:
This fTo cm be used single or multiple vvells
1.We0 Contractor InfarQmHon:
Ronald E:N eeter Jr.. r� 14.WATMZONn
FRDM TO DrSCRn ON
Wall CobtreefaNuame -_ J U j -
2960-A Unit R i
NC Well ContractorCer0cadonNumbeln C(1;''3 10n p(os;e�sln9
D�,NR SQ�tlon 1SomEec�rG �altl-awdweb OR1��R
FROM TO D1AM£TER THICKNIM I MATTRIAL
Southeastern Pump S Well Service Inca OL
Conepany Name 14Iluft�CAR'OR7'OBII� dowdlocal
FROM TO DtAML►TIIC TH EMMS MATMUM
2.Well Comsfe+setlon Permit!/:C V\) R R. is
List aft applicob r wee coma-V,n psnrrtts(ts.CoroSIX.Ssmr.Variance.CPA)
R R ia.
3.Well Use(cbecicwell me)- 17 SCRM
Water Supply Well: FROM TO I D1AbM7XM I SLOT trM— ITrffCaItF86 MATIItrAL
❑Agricultural l7Ma blic -"R R fit/ 1 C..
OCleothemal aieating/Caoling Supply) ideotial Wets Supply(single) ft. OL in.
Oladustrial/Commereial 01tcaidential water Supply(shy sz
FROM TO I EMPI.AMAM Mt TROD&AMOUNT
olei atian R
Non-Water Supply Well: ILOMoaitoring OR--cry ft
Injtction R IL
OAquifierFachmp ElCaoondwaterRemediation 1%UNDAMAVELPACK Mappikaliki
GAgaif-StaagoandRcoavay MffinityBanier FROM '
To MATERM SMPLACDWMhfETHOD
R R
OAgaiferTat OStntmwaferIkainege R
0EXperimental Technology OSubsidence Control
GGeothennel(Closed Loop) pTmow 2a DBILLIIfGLOG sttaef ad+fttlonl er..er lr
FROM TO oN color satrhaeaWalt SIXIL aw
Moothamal(A RCom) i 00thcr(ciplain rmder#21 Remarks) t) R ft.
LA 4.Date Wdi(s)Completed: R
R fL
3.Well Locaf>qur.�
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R it
ecility/Owns ewe FecifityII>0(if ) R R
R f!
h9a�Address,may.and TAP 2L BE!lfA8S8
Pky
County Pmcal IdnfifintionNo.(per
'Sb.Latidrde and ImMitude in degreeslmhsatalsecoods or dedmal dq"— 21 Certification:
if weU Sell are hillong is sufficient) 2
- Signshre of CatiSed Won Camaactor Date
6.Is(are)the wdl(sx. amsD or OTemporau7
BY xrg=q dsirfa m I herrby een*that the weft was(vac)caubuc*d in amordanae
wfth 134 lV AC 02C.01W or 15d NCAC 02C.02W WeOCambvcdoa Sbudards and dint a
7.L this a repair to an etdsBrg well• ❑Yes or o copy c,f this reamd has been provided to the well owner, '
If thb ra arapoa•,fiD-aetlerown well conrbveJion b far»mtion end espbba the swear of the
repair corder 921 remarbseedw or on the back of this)brm. 23.Site diagram or add"'snal well dehDs:
You may at the back of this page to provide additional well site details;or well
L Number of web constructed: comilmotion details. You may also ausdt additional pages if neoeeary.
For mdhpkbyectioaoram►wabFmWlyweftrOWLYwdk*e#meeeesber�an you eon
submd orx farnL 24.Submittal Instrrrrtlms-
9 Total well depth below(and surface: l (fL) 24a. For An Weds: Submit this form within 30 days of completion of well
For muhipte wefts fit aft depdtr ffdtffererd(momple-3@2W-surd 2®1W) Construction to the following:
10.Static wow kvd below tap efeatdtr=: 1 C i QL) Divhloo of Water QDaltt r Wormatlea Prviceaft a Unit,
.f"Ifr level&above eosin&use"+ 1617 Mall Service Center,Rakfgh,NC 27699-1617
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11.Borehole diameter. (br.) 24b.For Inleedon Welt:: In addition to sending the form to the address in 24e
12.Well construction method: ��� I above,alsctio to the
lt a copy of this fonts within 30 days at completion of will
A� construction to the following:
(i.e.suger::otery,eabl%&act push,etc)
Dhblon of Water Qu a ty,Uadeegrormd Injeldou Control Program,
13.FOR WATER SUPPLY WELLS ONLY; 1636 Mall Service Carter,Raleigh,NC 2769SL106
13A.Yield Wm) , Metbod of test: 24e.Far Water S-Mft&Gmlhnsreil Wens: ht ad"'to seeding the farm to
the addresses)above, also admit one copy of this form within 30 days of
13b.Dhdnfediou type: Anw®t; completion of well couxtradion to th`e oamty h=l&department of the county
where canattaated.
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Fours GW-1 Ncr&Camli®Depmtmad of Eevi=mein cad NatmW Resources—Divis of Water Quality Revised Jam 2013
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