GW1-2021-02385_Well Construction - GW1_20210722

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7.La this a BY d vft dale form,I hereby een0 dhm the Imil(s)war hMV)ConsOvow a aacordana
repair to an existing wall: Dyes or No
efth 15A NCAC 02C.0160 or 15ANCACO2C.0100 Weff 0niv acdonS/x*r,$w d thpr a
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23.Site diagram or additional well details:
S.For GeoprobdDPT or Closed-Loop Geotberand Wells haft the some You may use the back of this pop to provide additional well site details or well
construction,only LOW-1 is needed. Indicuo TOTAL NUMBER.ofwelis won details. You may also attach additional pages ifnecessery.-.
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9 Total well depth below land surfacer (R) Win, For All Wells: Submit this femh within 30 days of completion of wall
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1R Static water level below top of casio& �� (ft.) Division of Water Resenrcesi,fuformadon Processing Ualk
lfanterle►rJlsabaneetrstnpr use•_" 1617 Mail Service Centel•,Raleigh,NC 27091617
1L Borehole diameter: (a (in.) 24b.For Infection Wells: in additlon!to sending the form to the address in 24a
t above.also submit one copy of this form wits t►30 days of completion of well
12.Well conduction method: A.0 YID construction to the following:
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FOR WATER SUPPLY WELLS ONLY Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
•13a-Yleld(gpm) Method of test: 1 cko-�,(W- 24c.For Water Sunoiv&.election We[ls: In addition to.serubs the fort to
t the address(es)above, also submit one copy of this form within 30 days of
13b.Disititlietion type:, Amounts 1Gnz- completion of moil construction to the ebunty health department of the county
where constructed. '
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