GW1-2021-03559_Well Construction - GW1_20210823

828.622 72�1 P.1
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WEM!gQN*n7MJ0N RECORD IGW4) For Tntemnl Use Only.
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(ndustriaflCnrnmercial Residential WAiet•Stippty(shared)
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Injection Wcl:
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(i %Ve)1 frekt,nn4 IflOong is suflicloo) p , :r,Z,Certi Linn;
�.Js(arc)the wells) Permanent or DTempnrary star.er(krtirwd WeilChimz=r Date
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fluids ixrr repair,fill mukimm;waA4ronsr,tutipn u�armailon mri c f�rr!be nn,t,re�(,Aa efip r 411frr rrivird Aerbeat prat'ItYtnl to the Well awler.
0:19air tinder Of mma*,wai tt arontlic hack nflhixfami,
2.71'-:1IfR dtogt'>tm or additional Wait tdemtlLa:
R.F0,Gcoprche/OPT or C'Josed-Lanp Geotbarmal Wells lining Arc same You may use fhc back of this page to provide additional well sale datnih or"It
L-141Tuctian,only I CW.1 is needed GttGCtT1a TOTAL tJUMBER Df�vrlts aortatruction ttrtails. You may aim nftet:h addifiarial ptlges if neemmy.
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9.3110",well depth below land Surface: (R:) 74a. For Alt welts: Submit dsLa form willsin 30 days of catnpletion of%veil
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In.Statle watts level below top Of casing: Division of Wattx Rnmtreat'tn5►tratat[tm Proetntistog Undf,
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11_Rt►trttotedignrntrr: ' +r 1 (tn.) 241L For Iniertiay,}yJft to addition too sending the form to the addrm in 24n
I Wert eonatn►eflns method- f tf augtsve,81150 submit one copy Of this fawn within 30 toys of completionof well
(i C.taus•,minty,ad le,dims putt,etc.) construction to the following:
rM Aw TRRSf.ppr y WFt.L.4IINLY: Division ofWnler RtemJr %Underground Injection Canto)Program,
u►U Mail Swvirx Cerrsrr;TRAMP,NC 7709-1636
13a.Y1eld(gpm)_ _ t4Raetbotl of ttwt^-� Me.Cnr IMafar Qy�jy&(otaetlan Walla• In addition to sondmg lite ram to
ran.Dtsinfecnon type: Amnrtot• thus nddw.s(cs) above, also $6111nit onc'copy of iblo form ttithin 30 days of
completion of wall wasttuc Lion tD the cptmly tXUjIb dfglammnt off tttt:efn►nt)•
wtasre conatmew.
tmrn r North Cannflnnf]epnrrmontaflim'Infmnrnmi
QnAtfIY-JAvfA1m oettrar4r Reamnt:ee Revfwd 222-2n16

Well Driller Self-Grout Certification
Q4LWW-r
Owner. L New Well:
Address:S?-1 Wf MV-ki-X.6t22 LWI-C Repair:
Pmnit: W C_
I hereby certify that the above referenced well was grouted in appearance in accordance with
all County Well rules.
Well Dra'ller: ®Sh_p1!!`(YV'1®( 5 Signed: 1�---
Certificate#: `!13'1-A Hate G
Construction: Grout
Total Depth: eN 5" Type;
Ong Type: Mclmess: fji`p4e Cj
Casing Deptli J1 S gyp ; -
Diameter: 11,
Weight/lUck:
Height:
Drive Shoe:
GPM: �