GW1-2021-03414_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD Forlate=l Use oNLY:
Thb faun con be uW.for single or multiple weir i
1.well Confradur Informmtlun:
Ronald-E:Keeter Jr.. _ 11 WATER ZONES-
FROM TO DFSCRIPITON
Wall Cotaiseta Name U NLULI
2960-A sin. unit &
NC Well CormaetorCatEcationNumbor In�:3I�'a`�n Price
piNR Sect;on isovrEacT801M eltiraadwed oxln�lt
FROM TO DIAbDTIER• TffiCiII9l3s MAT>RtW,
Southeastern Pump&Well Service Inc. + t�_ - I �.
CampanyNeme 16IIsII�ECA.4irIGOHTOSRVG dried
lUq7
FROM I TO I DL4bMTMr I Tfncx'm MATERIAL
2.Well CondrocUom Permit#:l tt R. is
Lid ad applicable►8 oarm--mn panrin(it.Caasy,Smug,Vwkm@6 qWj
3.WeD Use(cheep well me). 17.SCiZEFN
water Supply Well: FROMqft
TO DU&WrrM L SLOT size TlffCla(ffi8 re.,�r.r_
OAgricuhnral O� • blip 111 Ia.OGeothemal(Heating/Cooling Supply) 'dentiul Watt r Supply(single) n to: V
01ndustrisycommacial Mesidontial Water Supply(shored) M URMT
C1hri
FROM TO EMPiAQ®1ffiYiMC[IIOD�AMOUNT
'm IL
Non-Water Supply Well:
OIHaeitoring MR000vay
Infection well: m IL
OAquiferReaharge OCrroundvsta Remediation IRSANDOG3tAVFl.PACH
OAquifor Storage iiOd Recovery Malinity Ba:ner FROM To I MATERW. O
PLACEMM"AdErf D
m tt
OAquiferTest OStc®wataDtamage n
OFxpaimental Technology OSubsidence Control DBII.LIIYGLOG attsse!ai�flanl sisate It
OGeot}tamal(Cicred Loop) OTrasxs FROM Ff-L
DEBCR�rION calvr sdVm& skitere
OGeothamal(H ' Retom) 1301her( (tin under#21 Remarks) IL � `l
�y
4.Date WrWx)Completed: Ott
S.Well Locatlon:
�
R R
ac> OwacNeme Fe&YM#(ffepplaeabb)
d �1 � 4�y �(( l �1 n IL
Physical Adhwk City.and Zip 2L BP,EfAEBB
CaaYy Parmlldeatifin icallo.(PIN)
SL Latitude and IAngkude In degrea/mimtes/seroada or decimal degrees: 22.
if well field,am bst/bmg is s,fficma)
2 . 10 Maf,�L(
qVf=of C=bficd Well Coubado, Date
6&h(are)the weft). Pane ent or OTemporary
By signing thir fornx I hemby ora*that the wed(id:cos(were)nmntrraciad err assmrdmns
with IS!NCAC O2C.0100 or ISd NCdC CZC.02W Wed Cans&udion SAadardr mrd that a
7.L this a repair to an existing we0: OYa or Mo aW of thtr record has been prvvidrd to die'wed owner.
if"is a repair,jV owkwwn wed eonsasredon it formation and esplous the name of the
repair raider 021 ranorbseedmr or on the boat of tkifi m. 23.Ske dlegram or addl-k well details:
You may use the back of this page to provide additional vmU site detsils or well
&Number of wdb constructed. construction details. You may abo attach additional pages if necessary.
For mu(dple byedion or nor}waatrmgply wdlr OAMYwtth the sme seasbxe dox.you can
submitotreJbrm 24.Submittal Instructions-
9 Total well depth below land sudaee: (fL) 24o. For All Wells: Submit this form within 30 days of completion of well
For,muldple weds list ad depdn IMP rem(e w*v--WW and 2®1M construction to the following:
10.Startle wader level below top of eaahtg: 1 (ti) Divhlon of water Qns ty.Iadorntatlea P wenfug Utdt,
lfwatrr level is above easbtg,oar;l" 1617 Mall Service Center,Raleigh,NC 276W1617
11.Borehole diameter. (ln.) 24L For Iniectlon Welk: ID addition to sending the form to the address in 24a
12.Wig eomtrvetlonmelhod: rt'� Il�J above,also'submit-a copy of this foi m!wm ifh '30 days of completion of well
construction to the following:
(Le.auger;totery.cable,direct push etc.) _
Division of WaterQuWhy,Uad�1-*0-Control Program,
13.FOR WATER SUPPLY WELTS ONLY: 1636 5M See oke Cerrber,Raleigh,NC 2769OL1636
13a.Yleld Wm) ID Method of testa 24e.For Wider Still*&Geot6ermat We1M: In addition to sending the farm to
the addrasKes)aboveq shso submit one copy of this form within 30 days of
13L DWnfeetlon ape: Amount. =vIction of well construction to&c abtmty health department of the county
where constructed. I
i '
Fomt GW-1 North Cemlire Depmtrnect of Ewitomment and Nateal Resources-Dirisionof Water Qua* Revised Tan.2013
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