GW1-2021-06865_Well Construction - GW1_20210429

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Physiinnii Address,
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S.For Geoprohe/DPT or C2owd4Lonp GeoMermal Wells having the same 11ou may use the tmdc of this page to provide adtlitional well site details or well
mnvmction,only,1 GW t is needed rndioato TOTAL NUMBER of-wells ctmstrudion details. You may also attach ttdditiotrel paces if nommary.
drilled: wswu iiai.mism1t:T[-ON8
9.T41,10 sve11 depth below hind suromc U+ fit.) yla, for A11 wells: Submit this form within 30 days of cmnptdion or well
1ermulUpfc«rpcU.aol;d.rprlsej,6�arenrr emph.3�f1,J4W'Mrd�Ili1007 emismianto the follolvia6:
10.Static WAftPtevcl below top of easing: (ft) Division orWater Restturces.Informatlon Processiag Unit,
*-Wr 1-1 Is'(Aw rwng.rae'-" 1617 Mall Service Ceuter,Raleigh MC276)4-1617
11.Boreholediltmeter. _,A".) �n 24b.ftr Infection tjX2W 1;,addit on to sern ft the form to the oddrasa in 24a
12 Well rnnettntffap 1ltefkod: rp:jQLj�.�t above,also submit one copy of this form wilMn 30 days of complaRkm of well
(I e.mt�,--Y.-bit.drm push.etc.) '-t Cottst[ttetian m the folTt�ing
Division ofVl'Mr Htamttnes.Undargronnd lq)eetlon Coate oa Program.
F OR WATER t+'t.VMY W Ei.L,S ONLY: i M Man Service Cermay RAtelo.NC 2709-1636
13a.Yield(gust) Method of test: Zir-,iFor Water Supply&tareMHan VYdIlr 10 addition to swd'mg the tinm to
the nddrass(cs) above, else submit one I ropy of this roan wiQtin 30 days of
tab.Disinfection type: Amount, completion of.veil construction to the cotuity health deplutment of the county
Where comaucted.
I nrtn(:W-1 North Caralinn Acpanment of linvlydnatmW Q.rol v-Division of Wotcr Ramurces Rewilkd2 22 2016

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