GW1-2022-05151_Well Construction - GW1_20220531

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This hTm coil ix'vsed fir.siugic as multiple MTlis',
1'WiAl:Cuuitmetor.16forinition:
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anyrj•,h au,4. I6.tNN£R CASING OR TUBING`e,ottierana►etuzed-hrt ,
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b Agri"Ittiral Cll PIlicipal/Patialic: 20 a ff. 30. ri. aaa in, o'.16 Schao Pvc
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taf4ntitferstata;eatx iiccnt �# t�init}131rtacr 17"- "R.: 301 It. Silica Sand 20/30
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1248 Bill Hall Rd, White Oak, NC, 28399 � fQ
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6.I5'taaCi' ihe.u'ell( : htrltlalttnt or 0RmjwrA4 Ay'stininb aldi fia>r,r,i irercdrp certify 410*-tlrg nrft{s)airy caaftryeted fir;accorddance
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tf 064 h o ffNTdr,faadt"it kfulrrw w4i vlm imr,rcdac dr fnrvirm;kw aM4 ritata3ar tdre rint,,rt raf'tTre
rrduvxrraateitiu11,rexararRraLcavni,r1i td,e.Lrar�:t 4Lds,farua. .21.. Iteditigrantor additional well detailis
You niu� use t 15aelti of this paw.#o proruCe additional well site detaiik-i f L"self
S.Number of*015 son3'tratted: 1 ceilistiuctiotti cietaits: 1'uu it F:ilstl:aitiacliadrliGcri al paged if necessbry.
fear,ir adrl t d 4YtdcNr:* ratn i-,P,a r vattadr r�Pil:ONLY n'3Eti rlia.srrm a crirrsrratrtdar,}�,.rvara
„s jaaraYmarr rF2: . .. .. . fiCTBMIT'1"AL IMUCTiONN"
0.Taifiieit deptlt 4eln 1,tnrinrfuce 30 (ft.] 24u t rir All.i4Pclls; Suhririt 6lsis fnriit Ertithia 3f►days stff roinptetitin of Felt
lai'+r atill2rdfrJ'c i�c-ddf'ddra;PFi�c�v>hr'�>fd'�i.raait�srrerra�Pr:3�'ytk�"a�td-2��d'k�') ¢anstnrctrq®:Cotl�faliziwi_ne,t .. .
10.Static water.16cl Ulan,top of eaishig* (i1t.) Division of Watt 116onree:i,Informatirrn Proecsiing Unit,,
if,ii rj er IVI'd_Is airove teisfev,use 1617"Mail SaTice Qiinicr;.tLticight it1C',27-40-Ib 17
11,gd hots Iliainctei.6° din.) 24b.Far tjWdap HOM ONLY: In addition to sending the form to Ilia addrm.in
244 abo�'e,.31sp p—btoit'a copy.of this hnn within A•days"of coinpletioii,of n011
12.,Wiglconstritiction e.thod: Sonic c irsrntctfaii td t1tefoll6itiaing:
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Division of Water Resources,Underground Injection Control rrol i°ittt.
FORS ATERSUPFLYWELLB ONLY:' 1636Mail St.rvice Center.Rsleigli,.NC'236 0-1636
13a,Vidd(gp'to) Method cv(tcst:
14c.-Fii Water Su�rpl,i K"fnlccti4u N clts:"
ALq"subniat o"Du copy of this fdim ttithitt 30 days of"colopletion of
13k bisinfi tion t pu Amount: t1Tii CcsnStiilt tirfn to thc count),1i 31til depaltms in-of floc=crntttfv"Isl:cte.
eoitstntctcd.
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