GW1-2021-08157_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD
Thu form can be u w-for single or.multiple wells For hateanal Use ONLY-.
I.Well Contractor Infimmadon: f
Ronald E:'Keeter Jr. I 14L WATER ZO s
FROM I TO DESCRIPTION
Well Contractor Name R R
29saA RfLf
NC Well Comrector Certification Number 11 OUTER Gt.41(G udN triad web OR
O DIAatETER- P MATYR
Southeastern Pump &Well ServiceFROM T TMCIflM Me
Inc. � - -.
Company Neme p/) �Ry 16 II�II�CA. OR TURIM c�
2.WeU Construction Permit# I�4 U FROM 7O DiAMEiPX TBIMGM MATI<SIAL
R R I Ito
List aU appfinabk wag mnrornrction patron its(cs.Cowry,Slnnr.Varkmg eta)
R R ia.
3.Wel1 Use(cheek well user 17.S.MEM
Water Supply Well: pf :
DtAhfErElt, sl.oT size TFIICIQ'tFBS TF.RIAL
❑Agricultural ❑MnnicipaMblic k I- ��• a
❑Geothermal(Heating/Cooling Supply) 'idmtial Water Supply(single) id
❑Eadustrial/Commercial OR=idmtW Water Supply(shw4 40
13 ation MA EhtPIACHIMIT MgRBOD&AMOUNTNon-Water sappy Wdl:❑MBnitoringMccory
InjecUoo Well: R R
OAgoifirrReehargo ❑GramdwaterRemediation 1ASANWGItAVFLPACB
❑AquiferStorsgeandRecovery OSatinitgBairier FROM Toetll�NT
OAquifbrTast OStornivAderDrainage 4MATERFAT.,
OExpe:imental Technology ❑Subsidence Control IL f
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG anise!aaNltiosH sieats r
FROM I To TDESCRIPrIoN fmim hadeezZ sdgrect&M Von Site,ere,
OGeothermal(A g�RRedlm) ❑other( hem under#21 Rcmarh) C
4.Date Wdt(a)Completed: ..J ' ' R
.Will!Location: fL
LLIJ�
fL R
Fecaaity/OwnerNeme , ( FeeflityM#(ifepplieable) fL fL
Physical Addnes,Cary,saad Zap \ EHEllSA$HB R ! 1 ° e •�'
�_ NOV9
201
County Paaaxl IdoatifacetionNo.gw)
5b.Latitude and I"Wtude In degreeahminrrtea/aecoada or decimal degrees:
(ifwell field one bvk=is sufficient) ..� 22.Certification: 1�n
: N Rr CA C04 I ql_2�M
of Certified won Cmbsebor
6 L(are)the wlaw etweanent or OTemporary
BY J19-9 tldrfa err,I hereby con)&kW&r teen(.)war(avers)cwsrbvrhd or aavrdwMV
� with 114 MAC 02C.0100 or 15A NCAC 02C.0100 W9U Consbveeon Staadardr and that a
7.h this a tepid•to an existing well: ❑Yes or�"'� copy of d&nerd har been provided to the weft owner.
1f their k a repay frflart ivroam.well conrtrvcltoa o formation and erplaur the nature of the
reparr tondo P21 remmb seedw or an At boa of t/ris16»n 23.Site diagram or addidonai well details:
>i`Number of web constructed: , You may use the back of this page to provide additional well site details or well
canstmction details. You may also sum*additional pages if necessary.
For meffipk oyeation or non wah»rrpply wells ONLY with the sate eaare w4WOR,you can
submit oneform. 24.Submittal Instructions:
9.Total well depth below land surface: V (ft,) 24a. For All Welln: Submit this form within 30 days of completion of well
For multiple weIIr fart aD depdcs ifdprant(marrple-31@.7/0.00,o rd 2@1 w) construction to the following:
10.Statie water level below top efeasing: L L 7 (ft) INvhioo of Wstw Qudity,..hdnrmQtfon Processing Uatta
ff watrr level is above car ft ace"+^ 1617 Mail Savke Center,Raleigh,NC 27699-1617
11.Borehole diameter. r l ) (irL) 24b.For Intectkm Wells; In addition)to sending the form to the address in 24a
(� n above, also submit a copy of this fain within 30 days of completion of well
12.Wen conettroetloo nnethod. 1 �J �l V� construction to the following:
(i.o.augey rotary:cab*&scat pub,ft.)
Division of wader Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELTS ONLY: 1636 MaH Sea v CerrtM,RdelrA NC 2709t.106
13a.Yield(gpm) t Method of teat• L 24c.For Water Sunnh&Gmtineu f Wdle: In addition to sending the form to
the addrsas(es)above, ablo mbmit one copy of this form within 30 days of
13b.Didnfection type: �'VA Amotmt• '.' completion of well cooshud{on to the county health department of the county
where ccwbucted
Foam OW-1 North Carolina Dgxatnuau of Eavaonmem and Natnsal Resources-Division of water Quality Revered Ian 2013