GW1-2022-05443_Well Construction - GW1_20220607

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4.Date Well(s)Completed: WeR IDif 707 n
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(if®allHeld.onalatrlanginso6eeiear) 22.Certification:
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23_Site diagram or additional well details:
L For GeoprobeMPT or Closed-Loop Ceotheratal Wells having the Some You may.w'o ItW hack of this page to,provide additional ma site details or well
eomtrpe ion.only i GW 1 is needed.kdicato TOTAL NUMBER of welts constnictiondeteds.You may also attach additional pages if neevm my.
drilled: (� r SUBMITTAL INSI'RUCITONS
9.Total well depth below land surfaea % G✓ (A.) 249. For All Wells: Submit this foim Within 30 days of completion of wall
Fm mntapro xsirs fur art depJu tld7(e>sm(ewmple.3(d}too one i{�laa) construction to the following:
10.StaBc lyater ttvd below top ofcasing: �C! (tl.) Division of Water Resources,Information Processlog Unit;
/Jvarerlerelif ohm carlagwe+- 1617 Mail Service Cch(er,Ralelgh,NC27699-1617
1I.Borehole diameter.�(fp.)
24f>,For inleetlon Wells; In addition to sendntg the farm lo the address in 24a
/ above,also submir one copy of this font within 30 days of Completion of moll
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l2.Well constto wo method:ducat posh,et o.) �(l - Y`l { wr�auaion to the svunwmg:
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FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Undetgrotmd Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-106
13L Yield(pdtrn) Method of test I,Dr. 24t.For Water Supply&Infection Wells: In addition to sending the form to
the address(es)above,also submit one copy of this form within 30 days of
13b Disinfection type: Amount: completion of wall construction to the county hm ilth department of the county
Where eumsbucted.
FotmGW--1 North Ctualka Dgmtmrat afEavuoameand QaaTry-Division of Water Room= Itav3sod 2 22 2016'
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