GW1-2021-00188_Well Construction - GW1_20210505

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only: Print FOi m
1.Well Contractor Information:
Russell Taylor 14.R'ATERZONES
Well Contractor Name FROM TO DESCRIPTION
2187-A 140 rc. )45 ft-
NC Well Contractor Certification Number fl• ft.
15.OUTER CASING for multi cased wells OR LINER(If il licable)
Hedden Brothers Well Drilling, Inc FROM TO DIAMETER THICK.NESS MATERIAL
Company Name n ft• ft. in.
2.Well Construction Permit#: Vo{b— ff n Q q a 16.INNER CASING OR TUBING 'eothermal closeddoo
1'i 1 /" Q ' ' 5 FROM TO DGMETER THICKNESS 'MATERIAL
List u!J applicable+veil cwrstnrcdon pe+nurs(i.e.UIC,County,State,Variance.etc.) ft. {t .-
3.Well Use(check well use): 4 ft. +5 ft. in. � )8& v C
Water Supply Well: 17.SCREE,I TEE L
Agricultural FROM TO I DIAMETER SLOTSIZE TH1CK\ESS 'tATER1AL MMunicipaVPublic fr. ft. in:
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
1ndustrial/COImneICial ft. R.
Residential Water Supply(shared)
lrri ation 18.GROL*f
Non-Water Supply Weil: E.N
FROM TO MATERIAL I EMPLACEMT'METHOD S A.tiOUNT
� tZ 20 R
emutaawneo pumped
Monitoring Recovery
Injection Well: ft• fr.
Aquifer Recharge oGroundwaterRemediation ft• tt.
Aquifer Storage and Recovery DSalinity Barrier 19.SAND/GRAVEL PACK lif a licable)
FRUM To NIATERL%L E'1PLACEMENT'IETHOD
Aquifer Test oStormwater Drainage ft, ft.
Experimental Technology Q'Subsidence Control fr. ft
Geothermal(Closed Loop) OTracer 20.DRU LLNG LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(ex lain under�21 Remarks) FROM To I DESCRIPTION(color,hardness,soit/rock tr e.urmin she,etc.)
ft. 5 tt. clay S sand
4.Date Well(s)Completed: Well ID# 5 ft, I fL
granite
Sa.Well Location: ft. ft.
r'�rt'tatlo�C7 fr• rr• I -`>1
Facility/Owner-Name
Facility IDd(if applicable) ft. ft.B�uoeralae 1'►V SV(VQ aZg`�'7q ft. I ft. I I
Physical Address,C d Zip 7 tt• fr. J J
21.REhIARKS t
qCounty
Parccl Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient)
22.Certification:
-350 �le-r7r7I N 083° ir7 3(n8 w
6.Is(are)the well(s) permanent or Tem ora g 4 0?9 a42
P n. Si nature of Certified Wcil Contractor
Date
By signing this form,1 hereby cerlh�that [ Wel/0)iras(nrere)convnucted in accordance
7.Is this a repair to an existing well: DYes or No is-lilt 15A NCAC 02C.0100 or 15.1 NCAC 02C.0200 Nell Causnvrtion Standards and that a
lfdos is a repair•fill out knouvi well eonsiniction h formation s�erplain die Hobo a ojdie copy of this record has been provided to the irell ox-ner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NIMMER oftvells construction details. You may also attach additional pages if necessary.
drilled:_ 1
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I55 (ft.)
For mit/tlple wells list all depths ifdijjPrew iermuple-3@200'and 2@1001 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Ifrvater level is above casing use Static water level below top of casing: _ �0 (ft.) Division of Water Resources,Information Processing Unit,
'•+'•
1617 Alail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
24b. For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: � �(� above, also submit one copy of this form«ithin 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) --' construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 100 iklethod of test: 24c.For Water Supply&Iniection )Yells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ) Amount: completion of well construction to the county health department of the county
where constructed.
Form G1V-1 North Carolina Department of Environmental Quzlit)•-Division o- aver Resources ,
Revised__„,
__0 16

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only: PCIIIt FOPm
1.Well Contractor information:
Russell Taylor 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
2187-A 7 rt. as ft. D -4.95
NC Well Contractor CeniBcation Number D ft. ft
I5.OUTER CASING for multi-eased wells OR LINER(If a 1(cable)
Hedden Brothers Well Drilling, Inc FROM TO DIAMETER THICKNNESS NtATEIUAL
Company Name ft.• ft. in.
2.Well Construction Permit : O/�f DIq-'��OJ�S Q�1" 7y 05 16.INNER CASING OR TUBING( eothermal closed 400
FRO\f TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pet•nuts(i.e.UIC,County,State,Ira•rance,etc.J 01 ft. ft. In.
3.Well Use(check well use): �9 NO,
gg ft. n� tt. in.' O�I�y p. c�I
Water Supply Well: 17.SCREEN O tI L•
Agricultural FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 5DResidential Water Supply(single)
ft.
Industrial/Commercial DResidential Water Supply(shared)
]tri anon FROM
GROUT
IROM TO MATERIAL EMPLACEMENTilIETHOD S A?IO1jT7
Non-Water Supply Well: ® tt. 20 fL
.e-saem,sn�. pumped
Monitoring DReeovery fc.
Injection Well: ft.
AquiferRccharge [3GroundwatcrRemediation ft• ft.
Aquifer Storage and Recovery 0,Salinity Barrier 19.SAtL'D/GRAVEL PACK it a liable)
FRO:•f TO NATERLkL EJ IPLACEME.\-METHOD
Aquifer Test �Stortnwater Drainage ft. ft.
Experimental Technology QlSubsidence Control ft. tt.
Geothermal(Closed Loop) OTracer 20.DRILLI%;G LOG(attach additional sheets if necessary)
Geothermal(Heatin&Cooling Return) 00ther(explain under#21 Remarks) FRo!"t To DESCRIPTION icolor,hardness,soillrock n e, ualn size,etc.)
Ct, FRENL
ft. I day g sand
4.Date Well(s)Completed: 4 � la► Well ID#
• graniteSa.Well LocatiDon: ./ aC�r IFacility/Owner Name Facility ID#(ifapplicable)43 C,asbj o R87/7al AOdrflss,City,and Zip 'fQ�7572--4-5N! n M(County 5 '`'i' E Sdr On
Parcel tdcn[ifica[ion\o.(pt\) y �'J�?",,.,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1,100119 is sufficient) 22.Certification:
1�35� �r7.i_9l n N 09 0 D5. 75K W
6.Is(are)the wells) Permanent or OTemporarT Signature of Ceni6ed Wcll Contractor Date
By signing this joint,I hereby eertifr that t ire//(s)nay(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or No uith 15,4 NCAC 02C.0100 or 15.4 NCAC 02C.0200[fell Constniction Standards and that a
Ijthis is a repair•full oa known well construction injoratation.' explain the nature ojthe cow ojthis record has been provided to the hell owner.
repair under 01 remant-s section or on fire back ojthis form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �O� (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple.hells list all depths ifdiJjer•ent(eranrple-3Q200'and 2©1001
�f
construction to the followine:
10.Static water level below top of casing:_- Ja0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,rise"_"
1617 illall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells:_ In addition to sending the form to the address in 24a
12.Well construction method: 1� above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rota °- construction to the following:
g rotary,cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources.Underground Injection Control Program,
L ��,, ^ 1636 Mail SerAce Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For 1Yater SuoDly & Iniection «'ells: In addition to scndine the form to
® the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Fonn GW-I North Carolina Department of Emironmcnial Quality-Division of\t'atcr Rcsotuces
Rtyised___�_i�_�_016

WELL CONSTRUCTION RECORD (GIP 1) For Internal Use Onlv: Print Foam
I.Well Contractor Information: _
Russell Taylor ` "J
1 `+�_ "` 14.WATER ZONES
Well Contractor Name FROafl DESCRIPTION
2187-A P,7,GY X ' 2021 1 40'
VC Well Contractor Certification Number li-rvi 1�3 IOfi
Pr=—'SSirN,1. Dl'l IS.OUTER CASING for multi-cased tcells OR LINER(if a licable
Hedden Brothers Well Drilling, Inc [)%a"ll vw�fln FT TO DIAMETER THICKYESS MATERIAL
Company Name ft• ft. in.
qq I p^ ^ C I 16.INNER CASING OR TUBING eathermal closed400
2.Well Construction Permit;:dRoao 90,19 C106 FROaf To DiAJIETER TRTCiuYE$S MATERIAL
List all upplirable well construction permits(<.c.WC,County,State,irariaice,etc.) 0 ft. L+0 ft. f_ in.
3.Well Use(check well use): L{o ft. L1 Q ft. LP
in YC
[Irn
SupplyWell: 17.SCREENCtlltllral FROM TO DIMIETER' SLOTHICKNESS
�Municipal/Public ft. ft. inhermal(Heating/Cooling Supply) Residential Water Supply(single)
strial/Commercial fr. ft. in.
Residential Water Supply(shared)tion I8.GROUT
FROM TO I MATERIAL • D&AMOUNT
ater Supply Well: 0 ft. 20 R. emersapumped
itoringRecoveryon Welh ft. ft.
ferRccharge E)GroundwaterRcmediation ft, fr.
fer Storage and RecoverySaliniry Barrier 19.SAND/GRAVEL PACK ifa licable)
FROM TU JUTERL4L OD
fer Test oStormwater Drainage ft.rimental Technology Subsidence Control ft.
ermal(Closed Loop) Tracer 20.DRILLING LOG attach additionalsbeeermal(Heatin�/CoOlin Supply
Other(ex lain under�21 Remark) FROM TO DESCRIPTION Icolor.A�raness,soiUrock h r rain size ate.)
Tt. O ft. I clay&sand
4.Date Well(s)Completed: / Well ID# 30 ft. 7� tc. I granite
Sa.Well Location:
1'0 �rI1�•S �C, ft. ft.
Facility/OtvncrNamc I
Facility ID#:(if applicable) ft.
a9e� Creed R-d wluwhee., ft.
Physical Address,C11yrnd Zrp ft I ft i
JPuzoo Cot,-"-N T159 C1-ie-ul(OW 21.RE:<LARKS
County
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllone is sufficient) ��y
C' T•
J 'XI
/
N �t a 3 p 3 22.Certification:
W i �I_
6.Is{are)the well(s) 1Permanent or OTemporaty T
Signature of Certiftcd IVcll Contractor Date
B}'signing this jara,I heretic cerl !Ilia/ wrll(s)was Overe)constructed in accordance
7.Is this a repair to an existing well: QYes orhexplain
No with 15A NCAC 02C.0100 or ISANCAC 02C.0200 lVell Constniction Standards and that a
ljthis is a repair,fill ad knousn well co nstniction information the nature ofthe copy of this record has been protided to the hell owner.
repair under#21 resat Aa section or on lire back of this jonn.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1
SUBMITTAL INSTRUCTIONS
9. midi well depth bedew land surface: ��0 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd�ereut(example-3Q200'and 2Q100q
construction to the following:
10.Static water level below top of casing: 1.570 (ft.) Division of Water Resources,Information Processing Unit,
If water level is aharr casing,use"="
1617:hall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in-) 24b. For lnlection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Lh �x � above, also submit one copy of this form within 30 days of completion of well
(i.e.nu er,rota t— _�=� construction to the following:
g ry,cable,direct push,etc.
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
4,� ^ 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)__&___ Method of test: WIa.J 24c.For Water Supply.& Injection Wells: In addition to sendine the form to
1 f 1 t� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1 VA amount: completion of well construction to the county,health department of the county
where constructed.
Forth GW-i North Carolina Department of Environmental Quality-P Q Division of/Cater Resources s ��>->
Remised _ _Uio

FELL CONSTRUCTION RECORD (GW 1) Print Form
For Internal Use Only:
1,Well Contractor information:
Russell Taylor g �' 14.WATERZONES
Well Contractor Name 9 FROM TO DESCRIPTION
2187-A MAY
7 7 ft, 58a ft.
NC Well Contractor Certification Number M1 t I X 2021 ft. ft.
Hedden Brothers Well Drilling, In9 15.OUTER CASING formutH-cacedwells ORLINER(ifa Ilcable)
77fvil't 3t Cs"5 I,r��as�lflg �I FROM TO DiAp1ETER THICKNESS hATERIAL
Company Name •Y,: ft• ft• in.
2.WelI Construction Permit M C�/D I&- 419(p- 7 n p- /Q r l 16.INNER CASING OR TUBING eothermal closed-too
FROM TO DG�IETER THICKNESS MATERIAL
List all applicable well roistnte!/on permits(t.e.UIC,County,State,Variance,etc.) ft. D ft. in.
3.Well Use(check well use): • 1 8 TEEL
ft. ft.
F
upply Well: 17.SCREEN
ultural FRUM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
�MunicipaUPublic fr. ft. in
ermal(Heating/Cooling Supply) Residential Water Supply(single)
triaUCommercial ft•
DResidential Water Supply(shared)
Irrigation 18.GROUT
FRUBI TO MATERIAL EMPLACENIE\T\1ETHODS.y.110I1T7
ater Supply Well: ft. PO rt.
toring "'"Q'd°"'�'•= pumped
Recovery
n Well:er Recharge E)GroundwaterRemediationer Storage and Recovery Salinity Barrier 19.SAND/GRAVEL PACK if a licableFt2Uh1 TUMATERIALEi<]E\TStETHOD
r Test OStormwaterDrainage ft. ft
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if ae-essay
Geothermal(Hearin Cooling Retum) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,rolUroek n e,eraln size.etc.)
ft. �iC ft. I clay 8 sand
4.Date Well(s)Completed: 4 19 .to2r Well ID# 5 fr. 7 5 fr.
granite
Sa.Well Location: ft. ft.
r I t Y�sf fr• ft. I ',.
Facility/O ncrName Facility IDa(if applicable) ft. ft.
&l- - - CreeK. Rd CuJlou)hee, a87U3 ft. ft.
Physics(Address,City,an Zip ft. I ft.
J gcwsa.� �ovar y 7537-4.1- 9 2I.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if welt field,one lotllong is suf)icienr)
35" 1
�- 7r73 22.Certification:
N 093• 14-31a W
6.Is are the well s Si nature of Certified 1Vcll Contractor /do
Is(are) (} Permanent or g Dat
8)'Signing this fonn.I hereby cerlow that t well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or No with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200;Veil Construction Standards and that a
lfthis is a repaii.fill out known well construction ii formation z explain the nann•e ofthe copy o(tlas record has been provided to the well owner.
repair under R21 neinarks section at*on the back oflhis form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL A'UMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1
n SUBMITTAL INSTRUCTIONS
F
9.Total well depth below land surface: D D (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depthr il'd�eient(erample-3@200'anndd 2@100')
construction to the following:
10.Static water level below top of casing: 100 (ft.) Division of Water Resources,Information Processing Unit,
IJwote,-level is above casing.use'•+"
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
24b. For lniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: - r h , h i.l above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) --+ im- construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 Alethod of test: IIaJ 24c.For Water Supply& Injection'Well s: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: amount.� completion of well construction to the county health department of the county
where constructed.
Form GIN-I ?Forth Carolina Department of Ensironmcntal Qu=lity-Division of Water Resources Revised 2?2-201 b

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only: Print Form
1.Well Contractor Information:
Russell Taylor F" ""
�a>A� 14.WATER ZONES
Well Contractor Name ! FROM TO DESCRIPTION
2187-A MAY X 2021 ft. )�;0 1- 4 0-4 45
VC Well Contractor Ccnification Number y It. l050 rt.
Hedden Brothers Well Drilling, Inc Ist':,r1; S'u +(,r,fO S.f:C�LjS S.OIITERCASING formultt-casedwelts ORLINER(ifa licable)
: t� r•i011 FROb1 TU DIAMETER THICNESS MATERIAL
Company Name ft ft. In,
p 16.WNER CASING OR.TUBING eothermal closed400
2.Well Construction Permit#: ARD - 1988o 7 9$ FROM To DL1AfETER 7AiCRYFSS <tATERIAL
List u!!applicable cell construction pernilts(i.e.UIC,Counry,State,Variance,etc) 0 ft. 9 ft. /_ In.
3.Well Use(check well use): pyc
r7l ft. lO in. 8g S Tr��L
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
�MunicipaUPublic ft. ft.
Geothermal(Heating/Cooling Supply) oResidential Water Supply(single)
ft. ft,
Industrial/Commercial Residential Water Supply(shared)
lrri anon i?f.GROUT
FRU\t TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: y9
L ft. ZO ft' :aces .,� pumped
Monitoring Recovery
Injection Well: ft. I ft.
_ Aquifer Recharge Groundwater Remediation ft• ft.
Aquifer Storage and Recovery O-Salinity Barrier 19.SAND/GRAVEL PACK if a licable
FROM TU dUTERIAL E�iP[ACEAtE\r JIETHOD
Aquifer Test oStormwater Drainage ir. (t
Experimental Technology Subsidence Control ft.
ir.
Geothermal(Closed Loop) Tracer 20,DRILLLNG LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Rew. Other(ex lain under#21 Remarks) FRoaM To DESCRIPTION[color,hardness,soturock n again siu,eta[
fr, R. I clay&sand
4.Date Well(s)Completed: +1101,0041 Well M# ft. DO ft. granite
52.Well Location: ft. ft.
W 11- "04" ft. ft. I
Facility/OwnerN'ame FacilityID#(ifapplicable) ft• fi.
4-`19 d�ia•wnd I I dqe, Rd w n.*.- a 8,129 ft. I fr.
Physical Address,City.and Zip �— ft. I ft.
Jna_W�sou� Guary 9 -31-744� 2LREhfARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient)
22.Certification:
350 42 9 4 N 0$3° lip.9*5 w
4 its aa�l
6.Is(are)the wells) Permanent or 07remporary Signature of Certified Wdl Contractor Date
By signing this fornt.I hereby cert'�that i uell(s)eras(mete)constructed in accordance
7.Is this a repair to an existing well: nYes or No with 15.4 NCAC 02C.0100 or 15.4 NCAC 02C.0200(Fell Construction Standards and that a
Iftliis is a repair,fill out knonti iveU construction itifointation i&esplain the nature ofthe copy of this record has been provided to the hell onner.
repair under B 2/remarks section or on the back of this form.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 pW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
1-� SUBMITTAL,INSTRUCTIONS
9.Total well depth below land surface: /00 A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ivells list all depths ifdiJJereni(krample-3@200'and 2©100')
p construction to the following:
ff ware,•leveh is above casing,use Static water level below top of casing: b® (ft.) Division of Water Resources,Information Processing Unit,
I( ••+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Infection Wells:. In addition to sending the form to the address in 24a
12.Well construction method: above, also submit one copy of this form-within 30 days of completion of well
auger,rotar
y,ry,cable,direct push,etc.)
(i.e.au -�� — construction to the folio-,t7ng:
l)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
�,, ^ 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: �WIaJ 24c.For Water Suoniv& Iniectiort Wells: In addition to sending the form to
i-t� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: a 7 E A amount: completion of well construction to the county health department of the count•
«here constructed.
Form G11'-i North Carolina Department of Emironmcntal Qualip•-Division of Water Resources Ravised 1-22 2010