GW1-2021-00321_Well Construction - GW1_20210312

WELL CONSMUMON RECORD F">*cmA U=ONLY.
This.fooacanbn used forsieSteora®ltiplewdls MAR 1 .9 2021
1_wen CoutraelorInformation:
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Sign a ofCeatiSod well Conuawor Date
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eepairaeaderPItroam siaafo»orontaebaafaftdajomc 2&Site dhW moradditionalwendetaf
You may use the back of this page to pmvide additional well site details or well
8�Number ofwsits eom>tueted: conskuctk n details You may also attach awl papers ifneoessery_
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subod' aeform. SUBbffffAL nYST MOMS
9 Total well depth below,toad surfsee: 100 (It) 24s.For AR Well:ti Submit this form within 30 days of completion of well
Far-,Wewta&fin all dgnkj4P-w(aemaplo-3(a120``0-ad 2WOn crosbuctiontothofoblowinl;
10.Static water level below top of wing (g) Diveston of Water Resources,Information Pr mabg Unit.
If ivater kvelIS above ar,ose^+^ 1617 Nat Setvioe Center,Ra kkb NC 27.6W1G17_
il:Borc6ole diameter. _(n.) 24b:,1+'ear Inieztion Welke ONLY: In addition to sending the.fom to the address in
_ _ 24aabove;also submit a copy'of this form wide®30 days of completion of well
12.Well wmtraehon method: coffihuclioli to the following _
(i e. relay,abk davetposk eta)
Division of water•Resources,Undagt�ed iajeetion C�tiol Progaam,
FOR WATER SUPPLY WELLS ONLY: I06 Mao Serowe Center,Rnleigb,NC 2709-106
13a.Yield(a-) Meihod of tesD >p�� 24c.For Water Supply&Infection Welts
Also submit one copy of this fom witbin 30 days ofeompletionof
13b.Dam&cdon type UMIQOS ►r%t Amomtt: 4ZI6 w: 'on to the county heal&depalmtmt of the county where
Form Ow--I Norlh C-1hia Depaehnmt ofFnamntocat mmd tiono Resomm—Divan otWater Rssomaes Revised August 2013