GW1-2022-01078_Well Construction - GW1_20220107

828-622-7241 P•1
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tndnstfint/Commercial Residential Water Supply(shared) la G p1I1P ._
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t,Aarc.wdl(a)Completed;V'O r's�Well1Af/ ✓�tr.
Su.Well i..nraHna: a�-�- -
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Sb.lAlitudr.Rod tnngtitnde in drgrt:eslmhlntestseennds or deeimnl drgt•res: -------
{ifs+clFfreed,onefit/longissuineicnt v t ;la.t'eltlf anon:
6.1,0re)the well(•¢)Opel,
mnnent or arrrmporary "o F.nfC`rrtifild WellCtmtrnator pate
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)i.+rpminl,•tAty,;;mt.1hrrrhvmnify thne lhr,wll(.+) me rwenl rrmorwMat uo a mMnm:r
,n pusa rrpalrto anexisting well: OVeR or «ddr 1.5.1.4'(W,n2C.Jima n,•LftlNCAC a2C.'•N;pO 1Ve11('�nr/melrlor S1aMlnrt(t mtrl that r.icompair..(rllrarlknarrnwellitfAM.711n,tib�•nnlr,r,•grrhu topyoflifftrrrnathnrhmnpmridalfiNit,well nmwt.
r;Awr inrder Of rrtnnrlrtYrrifnn ar tM tent hark ofllrft•.fanu. );l Sitt diagram or additional wall delAilst
R.Fur C'mprohdiiPT or C.losed-i.,otlp Geothermal Welht having the same 1'ou ntey r1�r.nu:hack of illis pegs to provide additlonat well tl(te deielle eir well
mnsirucrinn,oniv i GWI is nrrded, tlxlicaN TOTA1.NUMBER of wr.11s fnn9tlUatinn arlails. You may also attach titillitionel pages if noeessary,
drillad:"..,.. .,,.-.
7.Irernt well lteptlt below land surface: __(ti.) 2,k;t, F'or,Q(I W-ft; Sllllnth this farm tvitllin 30 days of complrilon (if well
Fr:r ntnifrpta+arac rrtt ON deprltej��erent(tmmpk.-4t?)OWnnd 1@1f10') C11ni1TPWou to The folloWing:
10.stoat:water level ktnw top of"Wing: __ (ft.) Division of Water Rtrnitrm Information Prottaieg 1,1011,
71''«nfrrG:vrUa,,hrtnncRr�ng,tur ^1 1617Mai1 Service Center,Raleigh.NC274".1617
Rerehole diameter: (In.) 241).Tor Iniection WCIls: In addition to sending the form to dtc addran h►248
l?.1Vrl1 ranstntctlnn method: above, "form within nbo submit one copy of this"for within 30 daps of completion of well
- cti.1)Irtietinn to the following:
(r e.auj;e,remry.rabic,direct imslba(e.)
I�R .i�S ANt.V: "-� Division of Water Rracurces.Underground lrdelction Control Program,
r 16,M Man Nervirx Cent.,Raicrgh,KC 27tcn94636
WA irift I Pplv WF 1
l da.V1rld(gpat) 10 iNethad of test. IV�{t(� 2•Ir.,Jf r t tq Suipigy.c Fnjgglan Wets: to addition to-Awding the rtnin to
tin: address(es) ahove, also submit one copy of this faun within 30 days of
rilsinfeetion lypcp�•—„•�—,,,,,,� Amount: - rompletion of w4l construction to the cony hcnith depnllmcnt or the ennnq'
whore c(mgt petrel.
North Crmlinn Pepnnmem of rin.•ltdnmer.11 C,hr11111y-Division of Water Romorcca Reuipp�;�2_2t11 f,