GW1-2021-03412_Well Construction - GW1_20210607

WELL CONSTRUCTION RECO t�D --4
For lntetmlUse ONLY.
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3igaetrae of CertiSad Welt Casttraaar Data
6 Ea(aft)the weB(:k amra4tt or D1empor1t7 By jV-T+p+i+1'-M t hrnby arty aw the Meaw war i CM)cw*w*d se ocro dmra
with I14 NCtC 02C.01W or IM NCtC 02C.02W Welt Catsbr efkx 3tondonb and that o
7.h this a repair tb an existing web: Dyes or BNo copy#/flit reead here beast pruvidedto the well owner.
1f d*tr arapab;X-abmwn weft coasbe .6off bob"M rdan and esptara tix noMM Of dw
,apart mtdiw 921 remmizsredim or err der bait ofth&fams 23.SW dlagram or add ttotusl weft details:
You may use the back of this page to provide additimd well site:details or well
&Number of wells constructed: construction details. You may also aft-h additional pages if necessary.
Fe,m dtlpk tsfecetmt or eats-wadrrsstpply we&ONLYwith the slew eaeeba400a,you ems
submit oaeform. 24.submhttat
9 Total wall depth below Ina.slutaeet. �_(fL) 24a. Fur Aft Wells: Submit this form within 30 days of completion of well
For rellpi'ew-Ar1Waf f&pdaifd*mat(ee=We-3(tg (V'aad2(WM) construction to thefolloveinf;
la Sbdk water t e ra below tap of emtns: lJ UP Dlvwon arwater Qua ft rtaematim Pltuce mkc U^
,jsvaarr kwwl fe above castsA saw"+ 1617 MaB Service Cear6 .Raktg6,NC 27699-1617
11.Boa elsok dlamreter:= _�(+tsr.) 246.Far Injection In addition to sending tho fort to tite address in 24a
A .l above,also submit-a copy of this farm within 30 days of eompktion of well
12.We8 comtrae#onmetbrod: �Al r 1 Jt. �� construction to the follovvmg
(i.e.euBeS rotary,cebt0.direct push,ate.)
13.FOR WATER SUPPLY WELLS ONLY: DtNsim�fir 'C � °O Contrd Programs
,Raleigh,NC 27699-1636
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13a.Yiel Walk) Metbod attest: 24c.ForWaterS z d eiMdW dls: In sdditiou to sending the farm to
the address(es)above; also submit one'copy of this form within 30 daya of
13b.I3tstafeetioa type: Amorme: completion of well oons6vdiea to the aZty health dell bnmt of the county
where constructed.
Fomrt3w-t NorthCuohnaDeparfimxnofEurnunamt and Nouna)Pesomcas-DivmmofWaterQw* Revised Jan 2013