GW1-2021-04171_Well Construction - GW1_20210827

WELL COxSTRUCZTON RECORD Fert�,Use ONLY: ,
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1-wen contractor Information:
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company Name I&MIERCASUN OR17TBINc -
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Water Supply Welt PRoat TO DMM67FB svorst� 1HiCKNEss titATt3t1AL
OAgliradtm II oMmiicipal/Public //7 R 1 Z R 7" in.
O cuffictmal(HeamgCooling Supply) OResidenual water Supply(single) R R is
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Non-Water Sup*Well: R R
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Injection Well: R R
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OAquiferStoragomW Recovery OSAinityBarrier FROM To MATFWALI INKPIArE11fHMIKE180D
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4.Date Wells)Ca®plded: �-i z-�w�l 066 2;E? w '
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Sa.Well Location:
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FaeilWOwmrName Faolily tDh(ifapplieable)
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Physical Addrem Cky.andZip 2L REMARKS
Comay Pared idemi5 No-(PIN)
5b`Latitude and Latgitmde in degrses/asinates/secomds or detramI degrees: air
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(rfvrdl field,erne taz►long is sufficient)
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6.IS(are)the Wags): I�Ye.II.t " QremM.Y By s Om farm-I hereby cerf&that the mu(j)was(ui=)conatruded in awo/dmm
with ISA ArUC 02C.0I00 or ISA AC4C 02C A200[Pell Comdnctim Standards and dine a
7 Isthisarepah mane welt OYes or-SWO aapyefibisawn; hmhemprcrdedeodnndrownv
ljrhts a o repair.fell ow bm�m well�raamn infwaraftoa and esp/aBr tLac mace ofe3e
repair wider:3!rawarfirsecd000ron&ehadrofddrfmm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells emosfroctok I consauction dem7s. You may also attach adddmoal pages if necessary_
Far mrdi(ple6pwanna.-M.ermtgdywe&ORYwo'k,saexoer�me6m�Yon Can 1IALINSrUCTIONS
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9 Total weU depth below laud amiaea j Z b i (It) 24a For Ail Submit this form witbin 30 days of completion of well
For—&We was ltsaffdrpthrlfdB-m(soa+pfa3(dl/?00•amd2@IM MOM MUM tothefollowing
10.static wafer levd below imp of easetg: f%� ! (10 n%
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lfwaerkvd is above cache$me.1. 1617 Mad Service Ceuta•,Raleigh,NC 2705-1617
11.Borehole diameter. l (im.) 24b.For infection wells ONLY: in additinn to scalding the fors to the address in
24aabove,also submit a copy of this fosm within 30 days of completion of well
12.Well construction method: /23 'i a,•�i- construction to the following
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Division of Wad Reaowu%Underground Injection ComtihA Piegram,
FOR WATER SUPPL.YY WENS ONLY: 106 Ma Scene Curter,Ralek%NC 2709-1636
133.Yidd(gpm) 1�r s Method oftaC Au-so 24c.For water Simply&Idedion Wells:
Also submit one copy of this foam wi 30 days of completion of
136.Din type GL '/t tv�k F pnw®t ! �JvmM conmuction to the county heap'4dt of the county wlrae
Farm GW-1 Nmth Cmotim Depmmnma offnrao®mt and Neumd Resamoes-Division of Water Ramuors Revised Aug sst 2013