GW1-2021-03583_Well Construction - GW1_20210823

828422-7241 p.z
Feb 1519 05;43p Clearwater Wall Drilling
'11 MLL CONSTRUCTION RTIr O GW x 17 ar lntcmnl UM My:
att Ointraetor information:
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crmsintctinn•eniv I GW"l is FWAcd• !•ndicata TOTAL.NUMBER of wells
drilled:_____,.... ---... �cmuQl�ltC7fAW(s'
A Taint welt depth billow land surfhact trOr lif rL jM.- SW=d Mis 1b1TM wWn 30 days of wmP]etion of well
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1].11ot>'hotedlamctter. �` ,_ (in.) �i8t►Rnr 1w eaon_W_rd(x to addition to txntting the tbrm it)dte adds=in 24n
J strove,nL+o u im t5 h env COPY Of this lore{within 311 flays OF COmPlellort of well
12.Well rnnttrueNon Mil tbud,_ _____ '1 --------, CflnSitIICllntr[AlitefOlrfl9Vrn�
(i e.anger,situp.cabk,dint push,CO.)_ inwilron erv`aeer 6eawrroes.lJnde�giOLnla ialeeaon Coatral Aregratd.
FXM WATER r&t,'PF4 V WELLS ONLY: � 1f36 mattSwdc*Center,Ratdo.NC 27094636
1Ja.Yield ilrPmt) "Cifind of test: 24Q&r Wratar 4n�ty& lartion WdR: !n udM9f to srmdhlg fhc lam l
the irddccss(cs) above, also submit Onc copy`af this fbtrn tvtgritt 36 days nF
t3A.gtslnfecrlon type, _ i►ptatmt am"latton of Well constraction is the comity itealtlt dapa(htuM of the MUM
Whore wrontrneted.
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Form Ow.t Npttht3omltrntDepnrlmontofiin-Irrimm,mtalQmenhr-Division DfW8WItcBoartae +

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Date. � -1
Well Case: Well#:
Name:
Address:_ i Y1e Or.
Pump has been Installed, well head ready for inspection.