GW1-2021-08147_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD For latemal Use ONLY:
Thu fors can be used for siogle or.multiple wells i
L Well Contmetor Information:
Ronald E: Keeter Jr. 14L WATERZONER R
FROM TO DESCRIPTION
Well CoaIIactor Neon R R.
29saA rc R
I
NC Well Condactar Cerdfieation Number 1S OUTER CASQtG amk egad web
DLIIUM- ORL11rII+R
FROM 70 T8ICX1vL46 MATNER AL
Southeastern Pump &Well Service Inc. � +� ,e.
Cacopany Name `s Its.IIoom CA�7('OR TOB pR`
2.With Construction Permit AFT.— , f�: TO DUbMTEir TMC3M= MATPB_MA L
List aft applicable we0 ovnsbvction pmnits(is. R [t
Cosanq,Soar,Varionee,ereJ
R R
3.Well Use(cheek well me): iZ SCttEEDi
Water Sappy well: FROM TO I DUMPTIM SLOT gdL 1TTffCt�BS MATaRIwL
❑Agricultural blic5�4�'121 'm ,_•
❑Geothermal(14catieg/Cooling Supply) identi.1 water Supply(sing].) ft. ter to.
❑laduabdal/Commerniai Mcsidmtial water Supply(shored) 1a GROUT
FROM TO ?EBIAi. EMFIAOH6lENT MlCTHOD AMOUNT
° .® R R
Noll-water Sappy well:
DMcoitaring DRe.overy
R R
Injecting well. R R
MgoiferRecharge CGrcandwaterR®ediation 191LSANDAMAVF.LPAML
FROM TO MATERIAL EMPI.ACIIYIEItTbllrfflOD
OAgaifer Storage and Recovery OSalinity Bonier
DAquiferTest OStormwaterDrainage C IL R 41XI'kDExperimental Technology OSubsidemx Control R R _i
OGeotherms((Cloned Loop) DTraeer 20.DBIISING LOG .trues■idboe d seats tr
FROM TO MaCKUMON mbr - solFtaea - sY arc,
DGeotitelmal 9 ' Rearm) DOfhcr( lam coder#21 Rmarks) tt R (,� 11 • h a
R R
4.Date weil(s)Completed: _
S.Well L R
R
R R
Facility/OwnerN a Facility (ifapplieahb)
R R
R R
M
Address,City,and Zip 2L RFMAHSB��� Panel ldar"IcationNo.(PIN) •...„;
SL Latitude and Longitude in dep Ma/minutes/seconds or dedmal degrees: 22.CertificadoD:
if weU Field,am let/loog is eimx) � � �-
t G N
' Signahae of Certified Wou camractor
ti h(are)the ww-(} ___t or OTemporary
By sighting drirf-M I hereby xrtiO Hut the weA(s)was(were)ceosbrm*i in acrnrdmrce
with 1 SA hCAC 02C.01W or 13A NCAC 02C.0200 Ne0 Combvemn Stardardr and that a
7.h this a repair to an existing well• OYes or o copy of this reeved hat bren prwldrd to tee weg owner.
If tlrtr it a repac,fill out lrrawa.well carrsbsreffore informama and espladr the rraarre of de
repair harder d21 remarks sactim or m else bark afAirform 23.Site diagram or addltbgal well details:
`` You may use the back of tins page to provide additional well site details or well
8.Number of wails constructed: 1 construction details. You may also ausr h additional pages if neoaswy.
Formsrlorple ngedim or sm►watarsupply walls ONLYweh sire Move earerbradan,Yw can
submit mrr form 24.Submittal Inst acdom:
9.Total well depth below land surface: (fL) 24e. For AD Wells: Submit this form within 30 days of completion of well
For nu&j a wefts list aft depths ff dICerew(a:="pls-3 t@21100'and 2Ud 1W) conatluttion to the follovag:
10.Static water level below top of c=hC: 'l d (M) Division of water QaaHty,.Infornattioo Processing Unit,
ff wooer lanel is above casurg use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (ia) 24L For Inieetion Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this f6rm within 30 days of completion of well
12.Well construction asethod: construction to the following-.
(!a.auger:rotary.cab*direct push,etc.)
Division of Water Qoailty,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2769SL1636
i
13a.Yield(gpm) Method of test 24c.For Water Sanely&Ceother 3d WdM: m addition to sending the form to
the addrsaa(es)above, also submit one copy of this form within 30 days of
13b.Disinfection type: A noaat: completion of well construction to tlie county health department of the county
Where constructed
r
Fomr GW-1 Narth Camtim Depasenem of Fsvuonmem and Natural Ramms—Divisimof water Qrnlity Revised len.2013