GW1-2021-03739_Well Construction - GW1_20210823

I'eb 1619 05,43p Clearwater Well DMIng 828,622-7241 P.1
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l,;v.rr, ta:g rtrtr,inrm•1 Anrhv�virlfjr iAo+the n�dl{�mtr lwerrJ carr+mdnrl+»octnMe.rcr
ks this a repair to An exirting wall.- QVes or InNo milk ISA 17AC:42C..0106 or ISA NOr--02C..0700 Weft CwWn. 'vj?9WW&4fAMrd+hm rr
rthJrkv a rq-fr.JIM me kno M W40 ew.wrrc+mai*rmallan 9upratI1br.xrrurinfihn G'P.gnf4l+'rrmnl hog b?mpmt-Mht+n+he well rMler.
'"Mir nadur all rem+entaateumr orrm+tn;Aackaf th,s,ram,. 2:&Site dmr)am or addltimW well dalalbn
8•For CctetprahetAPT er Chared-Loup Geotha'rnnl Wells having+hcsi me, 1Wu may use the back of this page to*vide atiditiomll well silo dowls em well
txim!unu:rlan,onhr l GW-1 is needed. f0d1 eta TOTAL NUMBER of nrllS eonstructitxl(hNaiis, You may aleto Mseb addilitmal pups If ntl mary,
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9.7fa10 iveJldeRtA Now land sut7ilcc; _(R.) 3.Itt• or AI! ,ells: Submit 11115 form within 30 days of compiv ion or well
1 er r�nlNp/e�rsltc+it+,ell d eprl4.;frll�enmr(uamp/r 1�A110d cad s�iTr f+++l J wwwkin WIN followft:
l0.Stolle water)evgl t>ctnx top of easing. --_,___._-(ft.) Division of Water Ratnlreea Iafarmatioul Pruaetsing Unit,
I)'x nrrrhns:!1F rdv+ve trrting,roe^•" C M17 Mall Sarviee Centel,Rgidgh.NC2709-1617
ti_I)orlRtotedltnnercr: l 0 (in.) 21t1,T++►E Infutillq)Vella~ To addidoo to smtding the loon W tltaad*m n124a
17-Well rnnstrncflon mettmd: ► y i t��-1 ahave,aLso Submit one copy of this form arllhin 30 deyc of compladorr of well
m, e,m mry.eato,ttra�Busb ec,) aormuction to the fl1lowing:
Divhlon of Water Remlu cues,Underglnand lgjeetlon Comm)Program'
713.a.
WATER SCM V WELLS ONLY! 16M lWail%Mae Cemxr,Rateigh,NC 27f�9.t636
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1BIrot) Mct)trr11 of lese ?Ac lior►Inter 3otseit &(oteetlt►a Wl11p In addidatr to swttllrlg the form to
the addlesg(as) above, also Submit onciaopy of,ihltl Form wllitin 30 days nF
13h.01sinfeetfort type; _ AmmmC eompk*imr of well consuucdoa to the county hoakh del n tment of the county
whore corou eted.
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