GW1-2021-03758_Well Construction - GW1_20210823

Feb 1619 06,43p ClearweiterWell Drilling 828-622-7241 P•1
WELL COIV3TR,7CTION 1A-99 I M 1).. Fnr lnwrnni Usnorally.
t. 1('nntrattorin Information,.
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[ndusirial/Commercial 13licsidential WatcrSupply(shared)
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(ii IWiI fictd,ono istnnnoiaSnifeicnt) 0t Ce ficatton:
6.Is(are)the vVell(s k3lp' tmtneni or OTemparary Sineolntc ort>ettlsntwaleaaCaemr Dore
Iry alptrrnt;+Nrr jorn;7 hr.+rhr cnrr�j:Mot rh+r txctt(i9,t+ar hantrJ cvnauadml m aetxrrAartr
7.in this a repair to an existing wclk MXes or No wQl t l iar.t['1);N 0 or MA X-W..07C..0100 WrJI CrotrJrnrtinrt Sratm4»dt mrd thm a
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mar under t Zl ivlaar0a sestltAt nrmt rllc Haut nlrbrs.rnm,• 23.Site dagrnm or additkutnl well debut$,
R.Car Gcottrohe/DVTor awed-1 anp GeWherMI Wclln having the smite Vou may use me track of this page to provide additeOnnl wet)She der tib of well
ix)MIT tC60n,onh,I GW-1 is heeded. rndicato TOTAL 14UMBER nhwclls comtmGinn details, Yeu may also it Wh addidoml pWn if rimcni ty.
drilled:
9-Total—11%kpth Now land sul'lhcos �R•) Yam, �r All WNIs: SUM*this forth�ritltin 30 dlg�of cDmpiction of well
lnrMnlNpiewrltelizreflddpllx;Jd/Barr.fitra mb*_ fFi?2f10'muti�iAilrtF7 cttnaiitsciiontn the 1011plxing;
in.State water lev,¢i besot.tap of tasing: _-_ �-Oo Division of Water Restoureee,laibrmatlon Prncwbg Unit,
Il'xroau lrcr!It rtttrrvn rn Yas.roc"•"cx� 1b17 Mafl Service Center,Rslelgk NC 274M-1617
ti.Boneltotediwmt ter: l' U /�)y 24b,Rw 1a1 ljQQ W�elrltn Iu a0don to bending the farm to Qte nddr0im in?An
i2 well conttraeHolt metk8d: �T 11W�"Ir above,ahe Submit one copy of this ibrtn within 30 days of completion of well
Path, - construction to the{tlilomm
mhtp'R .Mbk Aim.'( etc.)
Olvialon of Water Rtaat rm%UntiftraitnA lnijet:tion Col"Program,
(rlt)R WATVR titIM V Wi;1 Lq IfN LV: I M Mail Servlae Center,IAtic4gh,MC 27499-1636
13s.Vittd IRPM) ___ _ Memo.of test:�_ 24e,•Fer•Water Suninly&i Factlan WNI1: In addition to sending Iht Ilum to
/�c `� the mddrocs(es) above, also submit one copy of this form within 30 days of
1 iA,1)Isiarccttan typr; }(mow Amotmh c=pktion of well construcdon to the camtp heahh d[pannteM of the county
wkere contracted.
Ir^�C+IA+'l Nmfh Camatfna Aopnttmont oFlixvirtimnuntal Que,nt!+-I�rviartxf of Wal4 Rogtfatcea Revfass2-2&2&f 6

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