GW1-2021-02043_Well Construction - GW1_20210620

.lan. 24. 2018 10:58AM Env. Health - N.). 6711 P. 1
W1ti.L :QN§ RIICT1ON RECORD L(ff- ) For Tntarnsl Use Only. -
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7-Well Construction.
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5b.lattitude god ions in drgly seslraiahtesixeconds or decimal degmw.
(itwelllidd oaaltttllagitsr�dmt) 22.C
6 1s(am)The fweA(s) Permanlint or MTempomry 34ua6ao of Weil Cmaw or — p+16
Bq ti�ieg dra�,n�I beroby rinb d er the'.e!((t}vas(weJ mar&w d m omwdmnca
7.1E f his g repair to an e?SGthig deli Q Yes or ONo .irb lSd Xr-W 02C.0100 or 114 NCAC 01C.OXO FOR Coiuuueaaa MOVOrdr and der a
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rrpdr order e?/rvmrb:esdon m as the borF oJddr form. 23.Stta disgram or addifiosi(urn detgtli:
&For Geoprobe/DPT or Closed-Loop Geothemnl Weib having the same You tW use the btu of drm page to provide edditiooal will sac details or well
eOmgmt:tion,only(GW-11s needed_ Indicate TWAL NUMBER of uc& consWctloo details.You may 1450 attnah additional pages if neemay-
SUBMMALPLIMRIJ Lj
9.Total well depth below hndsatimm _J e G A) 24a.For AD R'eR>^ Submit Cgs hunt willtin 30 daps of completion of well
Formdopk vdis tmml AP&fdO—r—plc-3@200'aad 2100) consmwtiou to de ft111owing;
10.Static rater level below top ofcaf3mg: �d (D) DWWeu of Water:ftt=tourees.Information Processing Unit;
1/War 1stvl tr about aUbr&lure+' 16O.W1 SWACA Center,Raleigh,IRC 27699-1617
iL Borehole diameter. ` ((n) V&For inlectloe WeW Iq addition to s03ding the fx=m the addren m 24a
above,also adnair two copy al.'fhis lbtm ailhia 30 days of completion of well
I2 WeIIconstraetfonmethod: o *UVctiontothefollowing.
(�c mgQ mury,eahfe,ditto pudf,eta) - -
D'tvisian of Water Resottrorg,Ueda reuad 14eed6s Control Program,
FOR WATER SUPPLY WMU S QHI,Y: � I M6 ildail Sm-wj.%Ceaek Balogh,NC 2769-196
13L yield(UM) a �dhod of test J�C� ,For Water Sanntp&1e�We b addition to sending the Corm to
J ttrt:tldamKes) abovt; elm submit one copy of this txm Wfthuf 30 days of
131,,Wthtfecdon type XhI- Aftfentm L(/ twmpletift of well fOnstMCW)n to the comuy health dVamreat of the co"
where couchfteted_