GW1-2021-08163_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD For interns!1Jee oNLY:
This form can be used-for single or multiple wells
1.Well Conhuctar Informatldn:
Ronald E: Keeter Jr.. 1t WATERZONFS i
FRO TO DESCRIPTION
WeIlCdanactaName it (L
29saA fL
NC well Collowtor Capfi aboa Number iS OUTER CASING dltl nisi web OR LJ1�
FROM TO D 7ffiCHNESa MATERIAL
Southeastern Pump $Well Service Inc. >ti, � x r,"
company Name 161NIIVE8 rd.�+i('OR TI)SIIR` eland
N42-� FROM TO I Dumzrmr TffiCIftms MATERIAL
I Well Construction Pewit# R tL
List as applicable wt0 c»nsrraction permits(it.Cartrgy Seta,VarimrR era)
R R �
3.Wen Use(cbwk well use). 17.S __ ft,
Water Supply Well: FROM . TO ummnIIt�. ISLarSEZZ I TFUCIMM I MATMIAL
❑Agricultural ❑mu ' brie .11 r tc Ott I°1 1
❑Geothermal(Heating/Cooliog Supply) aidential Water Supply(single) tau
❑Induatriel/Commercial ❑Residential Water Supply(shared) M GROUT
FROM TO M EMPIACH4ffiYI D d AMOTIN f
o>m atinn �. ATERIAL
3 Non-Wider Supply Well:
❑Monitoring OR-ov IL R
Injeetibo Well: In tr
❑Aquifi rRed arge ❑GramdwatsrRanediation A SANDMRAVEL
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO. MA2ERJAL EMPLACEMENT
1ti fL
❑Aquifer Test ❑StormwaterDtainage
❑Eape:ineatal Technology ❑Subsidence Control fL
❑t reothamal Clued 20.DRILLINGLOG ate addtiiaaai Testa r
( Loop) ❑Tracer FROM TO DESCRIMoN rotor satMck se er<
OGeothamal(H Retain) E30ther(ccphda order#21 Remark) ,
r
4.Date Well(s)Completed: s.tr. m
S.Well Location: tt w
fL n
Facility/owncrName r FecilityM#(ifspplseable)
!t
R
I Witt, c lryu� !mil t
:cal Addins,City, Zip 2L 23Ef�A1�B
I1, �L INVY
ccurty Pz=l Ide ion No.(PIID
5L Latitude and Longitude in der ees/mirrowseconds or dedmal degrees:
if well field,am latgong is sufficient) !��L 22/CertlQeadton: L� h
t.7 N �� 1 -f w G'
` Signaoae of cat;sed Weu camas Date
6 Is(are)the wens). C mtneat or ❑Temporary By,rigs ddr!mm I hereby ctn*the the welf(s/was(were)cacrbvcad in accorda nr
with 1 St NCAC 02C.0100 or 15A NCAC 02C.0200 Weft Conatrrsaan S&wdardr and tint a
7.L this a repair to an existing well- ❑Ye�and
copy of this record has been prvvidrd to the well owner.
If thin le a repay,fraorrt brawn well consaucDon' the noovc of the
repair wider#21 remarb steam or or the bast of thisfinm 23.Site diagram or additional weB details:
You may use the back of this page to provide additional well site details or well
sir Number of wells constructed: 0 construction details. You may also attach additional pages if necessary.
For muWpir bytetim or ron watrrnipply welts ONLY with the same confi stain,you can
submit o e form. ?A Submittal Instructions:
9.Total well depth below land smrfaee:was (it.) 24a. For Ail Wells: Submit this farm within 30 days of completion of well
Far muf:iple wear list as depatr reforest(zc=gq#-3@7W'aid 2@l00) construction to the following:
10.Statile water level below cop of eming: (ti) Division of Water Quart lOnformatlon Processing Unit,
If water level is above caring;ash"+ 1617 Msil Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (hL) 24b.For Injection Wdb: In addition to sending the form to the address in 24a
{ r above, also submit a copy of this form within 30 days of completion of well
12.Well construction construction to the following.
(La.srgm rotary,cable,direct push,etc.)
Division of Water Quamy,Underg ound Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-106
13a.Yield Method of 24e.For Water Suonh&Geodmr rwil Wells: Fa addition to sending the form to
the address(es)above, also nbmit one.copy of this form withm 30 days of
t 136 . ' completion of well cautrudion to the county health department of the county
Disinfection types' where camtroetirA
I
Fomr G3W-1 Ncath Carotins DepetnmR of Eavuomixat and Natmal Resomxs-Division of Water Quality. Revised Jan.2013
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