GW1-2021-01587_Well Construction - GW1_20210309

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WELL CONSTRUCTION RECORD .w k,a,,l u,t olrcY:
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7bir hideoei let Hoed ftr,bo la i tatdtirlo wage _
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lepee..
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POC Well Coam.—Ce4o"to.NwrMa �r !� s/ S • ..rVCR
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CeatpaM Nerp
;.wen Cy.ae.aetie.PertoN r: taaut. i
fJrl�l fr Mtli{gl�grrRYterl/L•tlar(lee(•+ApY.Sr•a•,/o.Ma.V,we,) — � -_
1.Wall 11"(ebaek 0.11
.tarUpplyWtU: ee.._epee._.. • snMRaw tA�
GA�tatMlral 1 _W r,1.1;, A. R I is
n(3M%hwma►(HaUwoftlieE;lvipply) tiat paur 9c+,4ly(:iap{e) A. h, ! k► t .
OtndvaOieNCoatarat al Jtco/tdentier Weru Supply(shuea)
RUPIA42MMTKff.Ebb Mad
t]Irti inn I J k V h.
Nam Wettu be Weo!
Omonhor
OAquiftRocharSe _ .._....__._.••O���sourRemedulitpn rt vsL PACK i1a ^ " r
OA44Ar 9wreip enC It--very US WtY Barrier TV
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O[txperitetnta)Tee)rriop 0309-:4enceCotarui tt A
O(kot)+eeea)(C1awd LAgt) U'racwr ft
ru ai '' Itr if i •. :r�4
OOeothermN(HestlrkeCulptulg Return) CKj`ow(C lain tavhr#21 Kamaria) 1 h i h
4.JasaWer9)C)eny4laAiI2., or! .a/ Wr Vell _ Eft;
rt C� Ct h' P
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So.Well 1puNoa:
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OW lhy/OWva�Nw P�oility 1D�:iF.epnvblr) -... _ !
d p� D-1 h i FL 17 A rr
Ptryeiael aMr.04 CrY.sod Pq
c•"ry tutor!:dr bsa.tra Wo.WWI -
ft Latitude and LeMllituds is deareeduiaatzarweoadt or tkcisa.t dtelree : -
([ccrU fela coo 1rtAeaa is wtgetwt) >s.Corh attoa:
.36 '..a d l/ N 7 0 / �7� ' w `�;W -
arcrus" o'i('a votror vole
A L(Mv)tM re+ll(t)'Aetruaaneat or GTrtaprory
r riyrrtll rb..JMn,1 tit �'!M/W rvf//y vor;trr,eJ uwtpertrl/n aneetdrpar
WO/JAMACOr.0/pow IJAAK.-,WOX,'Q7p0 tI•!/CwrtlruerlMSiprJrr�vrlri rpa
7,is this a repair to an eaistiag wev: QYes or 110 ny.oJtlu pvoa!aes M•n/Ier/dNw/ae rv!1 owr.
0'*1 4 F"Wr.A OW hNnn wr//oowrtwrroa 40,%wiJa rwJ erAl r:r rAe roarrr of rta
rrrplr r•wlrr/1/prrvfrir ra•ew r rw+Ir era+k wrra4J►nw. M She dlegran or sddlHavol well details:
You may uac the back of dtis pope to provide aMitW*t well site details or well
!.Nutabew of wells toustraeteei: c.•xutr W AA dtr 11 You way also attooh addmeeal r4ps if w."p ly
Aar aeArrnle etarrita tr rro►wru an/{�trd GM_P wdr rk s.rwr tnrarrvrarw,yov otn
�J 5440 eysw•rl'A1.11't&•fU(TIANS
l+.TeAW weD 4tptb blow lead nrtate'. c` T r lftT I/a, Far At! Well Submit this Mrn: wtolil U days of cmpletiin or wc:'
'Fop-1904l 04*1r01f#04(/((j vatto,.v .-woo,and 2roIgo') CoMvA;;:Contuthefollowing
t 0.Slade water love,below top of wiad; �� /n) Division of Waar Quality,,nforwatioa Prviceerlag l;oit,
yr•wrr h«r/r,0i'Ow,wia=,err-r•- 1617 Afed Servies Coulee,B&kkb,NC 276fS�1617
11.Dose►obt dtauwta: `.� ... linej ':ab �► LILUP Belk: yt addition to Wr4ing he form to Iha amens IF.<a
ect., of .,r )t. . v tern .' days of comr1w.ion of wet,
12.Wau Caastratttaa tape_ _.. nr pelt ,a f fo:towtn,
f i.e.tea .racy,evbir,ft,'t par► —
ttvirM .nosy, ;_reetioa Cooled hotnea,
p'DR WATM vUFpLY W%LLq ONT.v. ail/ 169 M Service r Coal ,Raleigh,NC 37400•1626
13a Yield(Spa) l _ Mr.:ped N utt: L_o j, al W h =k•F,r Wrw dujwOi&LuecaplA IftlL: In d lilion to s000Ulg rum ru !o
tl!a AOtrela(n) above• also submit one Copy of this form within )G days of
13b.DhiakCttua type:C L G r I h& Antoout:_z d 6 2 oar piotion or well constrvottun to tha oeutty hWtb depamiial t c f flu cc,.aty
*Iwo co sUuctod.
n G1'/.! ►:vy,C'tn:rr Dr�arn'•tc.f avvort.::
rrl Ne.ret arte,.ars• r; i,
RECEIVED
1,'M X 9 -2021
Information Processing Unit
DWR Secticn