GW1-2021-07951_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD Fariatanal UMONLY:
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I_well Contractor Information.
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soar TO w►>txur. >aMnucMfferrrtnerean&wesomrr
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13Ceot6amal(Heathig Cooling Return) 130&w(.pb=undo#21 Retnarls) R Zd R
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5h.Latitude and L Wftde in degrees/minutes/secoads or decimal degrees: 21 on:
(cfwen field.one ladloag is m fic�t)
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SW=tme ofCauficd Wd1 Ca aaetor Date
6.Is(are)the weD(s): or OTemporary By stning dds form.l hereby serr6 Aw the wa(s)was(%wrO caa ara red to awanfi noe
wilt 15A NCAC=.0100 or 15A NCAC 02C.02M Weff Camaacaan Sft f,,v and that a
7.Is this a repair to as erisfiag welt aYeS or ON6' arpy gldnr raad has bee:aprunded m dreuW1 amen
4 rhis lr a rg air felt amkxnm vdl cons ancwa aforzaann an d ex#ain de,a nac ofthe
repair muler 021 m oar&secnon or at de hwkofddsJam. 23.Sift diagram or addWwucd well details:
You may use the hack of this page to provide additiarial well site details Or wen
&Number ofwdb constructed: construction detmts. You may also attach additimW pages if um sse,y.
Formaktptebg-Waaa,nazm atersapp/ywftONLYuq*ahe you a-
sabm roasform. SUBMITPAL INMCHONS
9.Total Well depth below land surface: �/ [fk) 24a.For AN Welts Submit this form within 30 days of complexion of well
rap erakWexe&Ito affdqda(f&ffcatt(a=We.JWo0-a d2@100') Construction to die fodlowing:
10.Stacie water level below top ofcas- 4 00 Division of Water Resources.Information Protesting Unit
1—kvri hahaecasht$Use-+- 1617 Marl Se rviee Centel,Raleigh,NC 27694-1617
1L Borehole diameter. (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
24aabove,also submit a copy of this,form within 30 days of completion of well
12.Well construction method: o®struction to the following:
(Le.-W-.may.cmcl fi -Puck eta)
Division of Wo-Resources,Undagroaad Injection Contiol Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mad Service C rater,Raleq*,NC 27694-16%
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13a.Yield fgpm) 7-0 Method oftest: 24c-For water Sm*&bdeetim wlts
Also submit one copy of this form within 30'days ofeompletion of
13b.DWmAwfien q Amount well construction to the sty heahh'deparmtcat of the oocmty where
Mstructai
Form GW--1 Nacth Carolina Deparaoxnt ofFavunaffik=d Natal Resomoes—Division ofWaterPimmuces Revised August 2013