GW1-2022-03371_Well Construction - GW1_20220314

828-622 7241 P,9
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VVIEI<.L CONSTRUCTION 1<tECORD fGWJ-1 [For lntentni Uae
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R.I nr GmprnAe/Ast'Tt!r�Atprd-I.nap GeM6cimai Wciis having nc�enmr. Vast may use.lite hnek of lhfg page to pmvide addiGCa d tact)rite demifs or well
m -M. T11atinrl,anit I GW-t is needed, tittliaatn TOTAL.NUMBER al'-wrtls coffitruction ttetail.q. You may also attftch ndrlitionaf paW if nocessery.
`1t'a nail K'etl depth iteltiW land surface: 3 ! , 444 yin, fsy., Submit this tbrm wfllrin 30 dugs of eompiciion of well
I�.:rmurriprc xrprri,r Mld p!!u•fA ��er7t(rxanrrlla-dt/MnR'agllR(A.IrM� consinwtiontothe folkn-dog:
ttl•Siatle water level beiotr top of casing: --(ft.) Ai doo of Water Ratitu'cee,ltdhraiatign I rocessiag Voll,
!i xvrh r in+v)rr dhlty cmrr,)t,1/w I•*• 1617 Afiff 5'arWee Center,IRolagb,NC274"-t61?
#I.R"nehMe diofietar:__ _! 2,W Fnr IF&rtilin tWL; Lf x"tion to storing tha form to the adilma In 24a
12 !Veit rooSlYlielhm meMeidt nbnve,ahn Submit one copy of this form+vitbht 30 days of mwnpiatinn of Well
(i 4 nn -------------••- cronslntctInn to the follarAnt
gc-,mho'.r.�hlc,dirniptult,etc,)
-�--- — Division oft4ater Refilntet es.Undetgragnd 14w.ion Control Program,
bY)R WATER A P"Y WFI.Ls ONLY: _ Ift3ti Man Servta:e Cenw,Rats
fgfi iKG'27699.1636
134.Yield(gpar)- 1 Z iVtethrtdof teRt:--�- rnr NrAt�r11 Br faiecNon Weltrr in addition to sanding tht than in
a.Th.Utsini tiott the oddims s(cs) above. also submit.one copy of this form wilhin 30 days nF
type. Amount: _ Ompietion of mdt tpnsttvcfion t> the comity hoalth deptittment of the county
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tlepnnment.nitinviaintncrrnl4+raflty•Division ot'ti+arer ftatsnt+rcera ltavised?.Z2-7.o1 f;
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