GW1-2021-05485_Well Construction - GW1_20211001

WELL CONSTRUCTION RECORD %f townd Use ONLY:
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1.wen Cooft"Wr infarmalim:
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2.wen Comeruction Permit#: 1(o6 L3 R R hL j O1y '
astaff aablaeeDpvmirs(E�Coma};SamV h#W# Mem) ' ,f
3.Wen Use(dwkwen ase)t 17.SCREEN
FROM •O DIAa3ElYs Sl ArSEM ITHKXNMS KATIMIAL
o�Supply W
«ltund es: odic R 7 R
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Noa�Vater Supply Wen: R R
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fulection Wei R
OAquiferRccbW ErAoundwaterltemediatian >9 SAPtDlCsRAVSLPACK
FROM TO11 DtA'[FRiAL awrw�tFxrett.reon
OAquifrr Storage and Recway Malimly Barrier
OAquiferTest OStotmwaterDaainrge R R
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Sb.Latitude and Iongitnde is degreeshminutesJseooads ordecimal degrees 22. Cation: j
(tfwen field.one ldflans is suffici—) Z
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S%mmmofCatified Well Omuanw Date
6.Is(are)the well(s): or OTemporary By slgrtng&is form:I hcm6y cc,,M�,that the urto)was(wael comrnraad in amvndanw,Q
,.ith is t NcAc ooc"otou er ire Ar,4C o2C:"020o WcgConnv&vamrSmndords and dwair---
7.Is this a repair tiu au eating welt Oyes Or Blip aspy 4Aft repo has h m pmAW m die wW owner.
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' You may use the back of this page to provide additiwtai wen site details or well
&Number of wens constructed: construction details.You may also attach additional pages if necessazy-
FormrdWe ormmwmersapplywdlr ONLY wttbthesmaea Y. M SUBMITTALINSTUCTIONS
submit mtefom
9 Total well depth below ION!sm face 4,d /ft) ?As.For AN WeiLs Submit tlps foam within 30 days of completion of well
For an*kweWioaNdW*#djfbem(amm#e 3@2op•and2@IM cmuftuctimatothefollowmg
10.Static water level below top of 3b 00 Division of Water Resources,Information Proeeamg Unit,
.we
ywarer teal tsabove we-+" 1617 Matt Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (io.) 24bh For I.jection Wells ONLY: In addition to sending the firm to the address in
I^ 24a above;also submit a copy of this form within 30 days of completion of well
12.Wen construction method: f(U40— coon to the Mowing
(Le.sager•may.Cabe,diioctposk ere) Div"mmn of Water Resources.UmlatW_I*Cfim Coetid Program,
FOR WATER SUPPLY WyELLS ONLY: 1636 Marl Service Center+Rakq*NC 2769 4636
13a.Yield(gpm) `� Method of test: 24c.For Water Supple&b deetma Wens
13b. t9Pc��� LL Also submit one Dopy of this farm within 30;days of completion of
Amount: A4F well to the county healtli dq tmad of the county whore
constructed. F
Form GW-i Non&Coofnm DeRaLmat ofEavw m s=ad Nmad Resomocs—Division of Water Resomms Revised Aogost 2013