GW1-2022-06951_Well Construction - GW1_20220722

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'Well Cordmcdorr Name !?Et TO tiFy(�it°Tltax --
NC Well Ctma tsr Caaift ation Dumber I _
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I Wall Use(chest;wdl Rare):
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OAf TO DLtR3!r£�'' SUSF B1Tt`K?I9iH MRT11R9A1_
Agriculattrat DMunicipavpu'blic --
�tai(l'lesti4cooling$uprlY) Residmutiai Watch Supply(skigle)
I��•'y � Residentiat Water Supply(sbactzl)
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Aqwl'ax Recharge --
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Aquifor Skuage and Rer,�ovety Salinity]3rrcaer
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A Teat 0%turrtawater Drainage a. -
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t�tlar:rmal(CIOSsd Loop) []Tracer —
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�.)�rndlttidm as®d lergl8tatle In+3egrsxstt rales/seeou ®.or d aa6 degreca:
(if won&kl,vus ltattlt+ag is sufficient) 2�. . �tdon:
6.IKan)the well(a) tts er nt or [3'1'euapor&ry Si lure of('ereRed°JVeil Coatra,tor ,�� -�1:�L
By 4krtng Rhin fwm.I he"Ay c&tVy that the xwa,')w=(were)cowoww Ras ac wrdwwe
7.)a thb a replr to an z'ide PR'ea: MY$a or ErNo wllh'15A NGAC 01 C.0100 or ISA NCAC 02C.0100 Well C,onsvuc&n Standards and thw a
If A&is a Maw',flit our knawa weU consmactioa infmrnarlon and erpiam the ruatnr_rt the cop)of this record has been pr&vid-1 to the a►wII owner.
repair 6 der 1,21 awsrvrls sertAm or on tha lack of this forec 3. Site dingram or mdaaltlonsl well details:
8.For Geosprabe/l3PT or Clese&Loop Geottherznal Wells having the some Yo ay use,the back of this page:to provide additions)well site details.or well
ttu
consirucdol4 only tA'-1 is awded. ladicate TOTAL 14UMBER of wells rono mctlon details. You may also attach additional pages if necessari.
Ty RATI�._rAll
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9.Tow sroo-zal dejA"+w lt>8d saarQne2: 24% For All 'Walla: Submit this form within 30 days of completion of%VCH
For aeW*11 ivad lilt all deytlia(J'd areal(exmnple--3@2&) and?�lo.•1(6) a to tEte taEEo
1s9 zatiC� 4s i! l bow t*of&A''Sirg:
-K) � Sflvlt�',on�uf-Water Resa Intarm>+fon F'trocfstliF{l
t'f v.�irnlrµr!is abarve cavGag,w:e"i-'• - ._ - >. ' #;...:.._."'......:
1:1 E6asroil�ale dlist�otsr •,,te+..�•��-,� ...4 . y.. _ 1617 t�Eni#Service Cao+tse It rIC s7649t-fi637 ...0.. ..
2461 llss Faalsctlra w1Ms In Mon to sen,iiup ttil tba tr tL.sdsiraas in 24a;
h' aho e„r,salt,.submit -of-thil,fomi•-witbiu,30 daya>of coanpletion-of,weit'
trltctlen illMhod.
c 9rniongo he fo'lot
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WELLS
�rM lvn of'L�Ytater Rea urces�.,f 4aderg!autad rcctlpn CatR6egl PrW
FOR WATER SUPPLY E LS ONLY: I636` l�aylo� asr,l�e3gle t;?963+p-fli36 -`
13L Yield d of test:� &r`aster SSuDDly�#In er�_tp��letla: TD t:dditina to sending the form to
sha adei*exis(es) a4�ove, ago s�Rbtnit ona rupY of this frnm s�'ithin 30,days of.
13b,DIdafecdon type: Amoa4t:.�_ M - w*r letion of well construction io the county health department of the county,
whce;onsniicted.
]Form(3`A/71 Nottb Carolina C:�ymtmout of Eariroui>nanlal(?ayality-I}irsiva of Weser liesoutua Rmibed 2-22-241 d'