GW1-2021-02786_Well Construction - GW1_20210805

WELL CONSTRUCTION RECORD
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-Ronald E:`K•eeter:Jr: la WATERZONES
FROM TO DISCREPR70N
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29saA R R
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NConeftwelon Permtt#: 1 U(, u pgplMII�II� rCA�1GOH tALDrtIIC� TEII
2.Well CJ MATISIAL
List all apptieable wall cvesatction penaiCr(En Caesay,S=.VV 4arimm ereJ
' R R is,
3.Wei Use(check wen me). 17.SCREEN
Water Snoop Well: FROM To DtAenrint i SLOTSM TIOCRIUM MATERIAL,
❑Agriaukural nicipavpablie 1 440 C:..
QGeothetnral(Heating/Cooliag Supply) idmtiat water Supply(single) R ft id
aladusbtial/Commetoial ❑Residential watt Supply(shared) CDT
FROM TO NAME" nfl% MM4r MtriHOD&AMOUNT
Q 8tion
Nowwater supply well.
❑ (anhoring Pt—cry R R
Injection R R
C3AgaiferRech-V ❑GratmdwaterRemediation r91SAD1DJGRAVELPACH
OAgwfbrStoragasWReoavery OSalialtyBarrier FROM 70 MarERJAL MEfLfOD
R R
QAgniferTat ❑StormwaterDtainage R R
❑EVetimental Technology ❑Subsidence Control
7ADRH1MGLO6 atheiadetttfeaalieadr
❑Geothermal(Closed Loop) t7Traee: FROM To DMCRIPrION color,hodeem sanhutic Mw zwh skk ere
OGoethamal(S ' Ream ❑Other( lain under#21 Remarim) & R
4.Dane wal(a)Completed: c R. R.
Wig Location: R IL
R R
Fecility/CkruerNeone F- t M#(ifeppH=b1o) R R
1 11�, C�• Y nC � {� (1 R R
hysiad Address,C dy,sndZip
t�Q IL 2L REMARBB ,
(PIN) UnIX
Parcel IdeuifieabonNo.(P s`n9
5b.Latitude and Lorsgthde in degrsahtalseconds err dedu al tt) eCglprl
Swell field err bblong is sutbicisrt) dui° 22.eertlAeatlon:
' e cf Certified Well Caot<ecwr
6.Is(see)the weH(s): Or.Mt or ❑Tempuras: By mV-g 0-farm,I hereby orn*Ont the weg(,d coos(va c)Gm,&m:rird w acsvrdatts
wfdr 15A NCAC 02C.0100 or 15A NCAC 02C.0200 WeQ Coarbvctw.Saealardr and dw a
7.Is this a repair to an esisd"wee: ❑Yes or rnpy of this record hat been pvvukd to doe weU owwr.
,(f tktr tr a sepals,frtT-owrlarowa weU ooasbrretiorr iafartaatioa and e�laer dr swerve of the
repair wader#21 remmkrmehoa or on the back cfAir form. 2&Site diagram or addpiooal wen deters:
You may use the back of this page to provide additional well site details or well
Number of web cons meted: A construction details. Yon may also atterh additional pages if necessary.
For w0bok nrechom or no;wafrrswpplywt1k ONLY wekBre eaeebtta0oa.yowcon
svbme art jean. 24 Subn*W Imteuctions:
9 Total well depth below land surface: iR) 24&For All TVelb Submit this form within 30 days of completion of well
For mwhiplewetZtlidandepdtrlfdi&nor(-w*-3@2M'oad2®1W) camtruction to the following:
10.Static water leval below tap of cmk g: Q M) Division of water Qaalfsj,Woenralion Prot:eetine Unit,
ff craar level is above carts&wm"+ 1617 Mall Servke Ce ,RaleV NC 27699-1617
11.Borehole dlameter. , (iu.) 24L For lakdian Weed In addition to sending the fam to the addteee in 24a
above, also'sobmit.a copy of this tam within 30 days of completion of well
12.Well contraction method: (� L I construction to the fonowing:
(Le.wogs;Mary,mb*daeet push,etc.)
Division of Water Quality-Uadeeurotmd Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 16M r&H Service Center,Raleigh,NC 2709-1636
13a.Yield Wm) IKelhod of Bart: 24e.Far Wstw Suooh ds Genl illill Wells: Tn ding the farm b
the address(es)above, also submit;one copy o 30 days of
13b.Disinfection type: ' AtDotmC ' completion of well construction to the county health depart wt of the county
whereconattncted. 9p2�
{ i !AUG 02L
Form GW--1 Nm*Csrobm Depamnect ofEwroment sad Nahnal Resomm—D"ion of Water Qirluy Revised Jan.2013
MC DEGUDWH
Central office