GW1-2021-02327_Well Construction - GW1_20210722

C M =S p11 �r�t U�
1.weU!"bate11actor tn*M adtoi:
�Gaey.Thompsoe� W
wou 4aauarft+as ly i
"I O-A us
atc wauc ►N,taabr
70
Aqua DflH, Inc. : . � '
TOC
cons"Nams.
a,well enact=Pmmtt*
List at1 gppllWblamdt aoraottonpesmar Ne ilt0 Lbw Uarloncea et4 tt: in.
&well use(cheekwell User . IL 1a
aberBUpplyw� v `
tonal mdcipailPlrblto.
tleathesntat(Htsdng/Caoling�Apty) tiesidmftiai Water•Saapply(fie) to ft �. .
lured WSW Sap*( ) 18,
inon
ldon"waterSuppvwdw fa. %tic Not,ek
onha tw fi
ulflnrReebotga �t3romdwaterl(emsdiatimt ' � ft •
quf>ler Sdusgeand Recovery Icy Banner 19 D qGTToRjM
uifer Teat iG fAgfL
mesnaI Technology OSabsideaoeconatm! +t
geothermal(Closed Lace) D '20.
Osaftoold Retina Other( loin under#219emwlm) i
4.Date wells)Comploled:&��2l weli m Q
!a.welt Loe ftm
ft. fL
Fddt7irytO arNaam Fadticyr WN Ofamtkabte)
t5�yetaoltidd<dso. ?ag 6L f .�
�- 1r•, 21. 6
Ginty Yl penalidaadfiaadonNaO" 1 ��
SLILsadladeandloo&deia ordedaadd r�P�r
Ofwdl Odd.anb9ongfosodtdent) 22.Q)erdRcattont �C�i:�CC �p,�yr a�`�"
.&G des M .YW N w �p ..21
6.Is(Uro)asevett( p
or Teu,ge ery s' of w �eautt►r Data
Is Sh a repair to an a ds9iagwettt OY'es or dit dos fins,t100 hereby
ar eerl�u elms d�a,rctt(r�I eras Deny COM&RcWx&werf n,sad arras
crab t3A NCAG e1C Atop oP t3ANCACBIC.ogDD i3'eiPterloaStmrdatslramT t6ata
ddr#taspetr.�Ta+tlmnrssu+ettMIN
bnattaaaaxlaakYdartatana+ye +PYaftJrtsreooxslmeBeeapmvtdeslwtt� ifaurtef
aeaalrrueArr+9?t iessartbrass nt oa ea rieabaak4lehlrfaxm 3L Site dtagtrase or addiSonel well ddeft
8. You may Use the back of this page to provide additional well site details or wall
For GcoprolretDPT oe Ciostol4.00g�Othexam!welts havitgtbssome
�only L GW 1 Is needed. Indicate TOTAL NOA�lM ofwdls You may also attach additonal pages�nece9sa�r..
drMed•
9 Totat wok doe below band mom � f>�) 24L M All�;►attsc Submit this firm within 30 days of"lotion of well
ForaariWMualkUuattdapths d t(a pta�3�3 � Z�tQO') """�
aetietcto flustdlowiqg:
it Stairs waterievd below top afeael (il;) Division of avatar Res w u%IhMwmWoa Pr4us t g knit,
Jja+atwkIW&cbm canva on"+" 1617 NO Soreiea Cen4at',Rateiglt,NC 2769MG17
1L Sordcale dis>nuttar. ft) Ubr Phr Tnillop in audition to sending the fine to the ad =in 24a
w� method: if above6 also submit an copy of this form wiWa 30 days of oampletlen of well
�--.. construction to the following:
PA mom satiny.able,dbw posh,eoea
Division of Watex Resources,Undo' nd Igjudon cowrol Fragrom,
FORwATERSUPPLY WRI LS ONLY 1636 Nell Service{�Rr�,NC276' MO6
UL Yield(gpm).._._L_._.._Method of test:� � ;•4t'C: ',?AL%r water Sn elk lniecztan Pi►elisa in"lies fa sending the fataa to
the addresses)above:, also submit me copy of'MIS ft=wifhhc 30 days of
.13b.111daitiedon me: cumpietion of xeli canstnutioa to fhe'eounty health dapardnent of the cmutny
wherocxnstttceud. 1
Faun sCw-I Nesdsf"roaroliaoDapnrts►aatof6a+dread►aataltjndiq.-DivlaiedoEtVateeR�omea ttaoFeac/2�1b