GW1-2021-02361_Well Construction - GW1_20210722

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7.Is this a $YO B rids fam>I herrby eert�ukm r/m:reNM tray 6MV eaasoaered m aeawdaaea
repair to en eaistingwdl: �ce or 0 +rfU,15A NCAC 02C.0100 or/St MC0tC.0100 JYallouvmdonsm*r&wd tbat a
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�+onhasa6rd21 � "` 23.Site diagram or additional well Malls:
R Far GeoprobdDPT or 43osed4.00p Geot6ermd Wells having dw same You mey use the back of fibs page to provide additional well site details or well
man,only L(i1A►-1 is uuxded Indicate TOTAL NUMBER of►vells• construction details. You may also sunob additional page ifneeessgq.•.
drilled*
. SUBMLTTAL 16V�PRUCTIOPiS
9 Total weU depffi beittw bmd sosface: - t4�F. Submit this Porn widen 30 days of completion of well
/brmehlpfeUv&89aftdaprh*g'ddamftwp►a-3@=mrdZCaIM constructiontotheibllowing:
10 static weber hvd below top of easfiog: b (tier DiaMn of Water Resources,inforaoattoa Processing Unit
j/lnorarlarot�abaramring ere 1617 MR service Center,Raleigh,NC 2769NI617
1L B°ra6°le diamatera (in) 24L For Ialecaion V► h. In addition to sanding die foam to the address in?.Aa`:.',..
11 Well eoustrnedou meffiod: CO4-1,r y Al, above,do submit an copy of this fbnn within 30 days of completion of well
Caa.a rotary.eablR diteotp,eh.ems construction to the following:
Division ofWater Resources,UnderIffround Injection Control Progrem,
FOR WATER SUPPLY WELLS ONLY 1636 Mail service Centerelgh,NC27699-1636
'UL.Yidd(gpaI) Method of test: 24L For Water SnDn1V ell Iniee6on In addition to sending the form to
k� o the addresses)ob=6 also submit one copy of Ofs Porn withbt 30 days of
Aft DhInfiction type: 7 Amonat:�,G _ completion of well construction to the coiany health department of the county
where constructed.
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