GW1-2021-02796_Well Construction - GW1_20211103

g'ELL rvONSTRUC[TON REC,O,-�� tGW 11 ForInteraal Use Only: �,
1.well Contractor Information: - ,'I—\
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a.well Use(check well use): M to
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4.Date Wago)Completed: 2� wen 1D# R�_ tt
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/1 Faality IDO(ifappiicable) & 8
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sh Ladtade and longitude in dgees/minatea/se¢onds or decimal degrees:
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22.Certification:-
6 Is(aft)the well(s): ermanent 'or OTemporary a 76 6 1 SigaeLae ofCud w ell Z
� Dam
7.Is this a repair to an existing well: CM6 or QNo � d°' 11"' '�►njyrMrrlunr0s+atr +.Uetrtraseµarjlpo,edvse ,� 15AVUC'02C:OIOOorISANCACO?C.0?00(�eQ mOOO° Oe
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8.For Geopt kMPT or Closed-Lao &Wng 23•She�m or addltlonal well details:
col �,�Y 1 C3W-1 is•aceded hhdiedte TOTALw� the same You may use the back of this page to provide additional wdl conk h6
drilled NUMBER of wells (add'See Ova'M Rem Box}You may also atlwh 8&hboud PWM ifntsoOwY.
9.Total well depth bdow land surface: �O d 14•SUBMi1TA+L Il MUCTIONS
For mhrinple we&As?all dgda gf4% w a(a)?op•a»dI®t001 (it) 3nbmlt this GW 1 within 30 daysof wen eo letlon
mp pat the fallowing:10.Stack water krd bdow top of eaeing:. 3 24a. For All
IJ++ntoterdttdbo+aoim�ft;--+• (it) beornuttr'. �11k161him to on of Water Rwources (DWR),
11.Borehole diameter- !/y �NC 27699-1617
(m.) 24h For Itlectl�n winCOPY to
1 'am,1636 MSC,RaleiA NNC 2 6 9-1 Uindaground 1636 �1 (NC)
12.wetl eonstrnctlon memos:
(Le 10°'y• .daeagmh,etc.)-- 24c.For water Saonty sad Open-I,000 GeoWerural B wdta
FOR WATER ooU*en.U-- C%u•QepMTMent o yu C(W to the
SUPPLY WELLS ONLY: tYae— ins ea
24d For Water weIIa rvdincl>r over 100 00 GPD:Copy to.D1i+R,oCPCUA
13a.Yldd(gpmj Method of teak c r p°�t��&u>sm�i 1,M C, ej
13h Dldnfadoa type �.
Amount: ''✓
Form OW-1 '
Ndtth Carolina Depa"E=of lmvaonmeatal
QQWtY•Division of Water Resowers Revised Cr6.2otA