GW1-2021-04310_Well Construction - GW1_20210430

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5b.Latitude and longitude in deireestminutes/sa ends or decmrai degree:
(ifwen field,ore}VIM is said) 22.Certification:
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6 Wan)the well(s): LAe m-ut or DT rary 2 9� I t
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9.For GeoprobaMPT or Closed-Loop Geotherm al Wells having the same You may use the bark of this page to provide additional v&constnwbm info
uctitm,or>ly 1 GW-1 is needed.Indirlte TO. NUMBER of wells (add`See Over'in Re Box}You may also attach addit�oel pages if necessary
dulled 2C SUBMLTfAL INSTRUCTIONS
9.Total well deptlt below land surface: 29G (ft) Submit this GW-1 within 30 days of well completing per the fellosvurg:
For=&*-wellsIw alldWJ=ifdfffe—(rsompre-3 00'ard1(nZM
AA 24a. For All Welts: Original form to Division of Water Resoraoes (DWX
10.Static water level below top of casing: V ( ) )tm din processing Unit,1617 MSC,Raleigh,NC 71699-1617
If water level Gs above
' b {m.) 24h For Infection WeBx Copy to DWI Undergmmd Injasion Coatrol(IUC
1L Borehole diameter. RD ram,1636 MSC,Raleigh,NC 27699-1636
11 Well eonstrwden method: �r" 24c.For Water Smmly and 2pLD4AM Geotht:rmal Ream W r Copy to th
(r.a=Ww,:otuy calk&redp-k etr-) county environmental health depatnent oftbe county wbese installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells IrodncisQ over 100.000 GM.Copy to.DWP,C�j
Pemrit Pnogrram,1611 MSC,Raleigh,NC 276999-1611
13a.Yield W* IS ?&thod of test
13b.Dish&ction type: 1 ount:
Fomz GW-1
Nall h Carolina DewofEmmo=maWQuality-DivisionofWatchResauras Rsvised6-6a201