GW1-2022-08187_Well Construction - GW1_20220519

-----
828-622�7'?,'�•'I
-"T
F-f)t) 151906:43p (;IearwatofWBlfUri111nn �--�
WELL CON CO G'1� •,�mr Tnicmnl Uso bzily:
I.Wrll C,nntraetnr Informrttlo _ ----• �S6 _
�..----•-•-r--�^---r-
^-^-^^-'— tR
Well ColitlactiX 11911m �
uv
R c t; c�tal w ► 1W�-
?IL'Well Cnntrarlofi:ettliRcatln Wffnber �/ ! film T f,
I ItYGflR CMtlraMt L
CompnnyNmm� «� Jill 1p IOU
7.1YcU(:nnnlrnaiEon�'Rr+nit#: "" t' -
f.(rt aft aplrl(twhfu ivefl rvrnrtrNnlfottJlarAtat Q,tC tJlt$Cmralj Sfa1a.Yarlancc,air") �k to
tv.
1-Will the(Check tvrll 1110: - as C N ittlB a
WtttaYSuQ�Wci1: "1°ON` � �
tmiciQCllPuhklo f,1 � d'
Agrieulttirnl .. � lo.
Cic-own 1(t•Icating/Gooting supply) esidantifil Wator supply{011810 t+•
tudusirini/Cammenatal Resida eml Water Supply(*hArD0 ""a IJT . C
Manit4rht Rtmovary _
Injection n" R• -"'�"M
Ag41fit'Rimhatfr �graundwntcrltalnedlstlnn P. ,3Q►p►� yrgL AC g ?L J = men
SNinity i3Atrier �'^
gmmtwatcr
nrolnngo
AcplktirTrst 13 -' It, Ili
Experimental TV1100169y 13Subaidence Cnntrn!
Cranthermal(Closed Loni1) 07(am -
0llter,(aXpltlq, nundar#21 Rcrnnt'cs} r�
CJeathcllnnt(Haattng/CoolinR Rctuml � � •�
a. __---- ---- •-
t.Ot1fcl7t►di{11)erl Welltmr
ern \ADrImWell Location,
r / Faciltry 109(-Vnlic li .)T_
cilih:()umcrNtnnc . !ice� T7 i 1-
Physlrnt Addras",Pity,and Zip AR - -��s_L�L!!-..�..-•----•� karaef fdamitirnlion No.(PM) ,•t�i�-_.._4^'""".'.o.._.._.•�--.•►+ �i';.4��-.•i,��1 _._.••--
C.onn(y
91).1I,411fude nail ionAltmileindegree0oninnteS/SecandsordealronioCgrvm% r-- -�-- U:ti^riiil,.;l:' ,.•. _.i:i,`, ';Ji'ii
6 wolf frdtl.nn;1100130 in901ltnlent) p ;;1,'r:,+Cart CAtlan:
A�k.Z ',q Q4Z51�
- G1a11
.;11 ninrenNefll IN DIdlemtromar
C IfOrt:j Or welf(R t't+mnBeat or CITempornry
J.(u,rfFrllnJS rests Jl,rnr,I hrmFv exrrrlJy+that the,�it`a3 nvrr!F'errl arltorNR'l!!!!In nu.Yrrddtrr.
x•IM 1SA 1 itim.A2C .47 ko or MA rV(.AC dK.'.IJ100 Well C.'muim'ouSlandards rmllhal.r
i.lfq tlltr R repair to An CXIYtIpg well: �xGx or5010'7h
lVon lh s,ulnn,e r/ihn G>I?1r ofdrls reran?Ifni,MA
lOt1tL Wcff nwltfr.
J,l'A,1.r xs a rrpalr.J111 m,r known rvrll aonstn,rlfin upF+I Galion
ralrolrtinder All romarkrAviiin Aron Ifir Porkaftb(s.fam+• -2,L Stfin♦HlRrmrn or additional wall dtltllta:1"Vide pop'
the wall alto dm/tlls err well
u may lisp' he lmck or this Ia ltddilwal
A-ForGenprabe/UPTor Ctowd-Lonp GeotA l We"A baVkng the"Mc c11r~9trur�ion lrrlals. Will may Him alwh addltinnet pairs If na mery.
txmvinrcdinn.anty I GW.1 is needed. 1'ltdimg4Ta'PALNUMBER of%vr•11e
ritnrM i t14'41'RtIf.T�.Q1�
ays of completion of well
n.7r+1tlt NYC,,tkptb Dcktrw hind 0110 sG1 ---( ? 14a. snr Alt Wrlle; 9Ufst»st this tattn within 30 d
ri,r Pill Wel).V tixr nri dtPrltr lfd!„darnnr{!•.ra#11 3(n??1/11'aqd:fir 1D(1'J cimatrileltiln in the!'ollolvlttg:
I)iv atrta7 Ma$Serykcc COMO��dllh NC;t7OM 91 vUnit,
' 111.Stt1Ga Nttttlrlf~v4t below tap of cAtling:.__._ �..._TA------�--<Er_l ,
!f water llrl'rr f8 trhnrn Man,11AC �
It)addition to lending tha Itntlmt Iv fife addttt�t hi 748
li_Aoneholedltlmetcr, {ln.} abom A�24b. ear copyofthin form wklbin 30 drays Af aompledllttn of Wdl
IZ%velt conitra@tlon mQlbod; --T_ etaasuuetion to the following
(i n.Hoar;-,rotas•.mule,illrgat(n,rh,cto,) it Im og
rn
_ DlVllinn ot'�atE('(tlDRI11'ClS,Undc uud 1< eetton C.oAtra tnr
t�OR WATER-Suppl.V WELLS ONLY:LY: — ZG36 Mat[Servloe CA101M,Ritteigh.NC 270519-11536
"Roma of test _ .Zit r' ur ■, CuerdL'&ipjeeH6tt Willi: In udditlen ro sandltlg the form To
t31R,YirtA IRI►111J -��_ the aildross(q) nhnva QUO Submit can Copy of this t'olnr within 30 days a
tab. type- Atno,rnt; ��i aamptogon of.veil construction�the colony health department of the county
1)Isinrecftan
-- vnixre conifrrlcted.
Vm,nCW-1 Nort1r(hmlirm!?npnamnntnr'1?n�Irrtnrnrnr,lQuafll+•nlvi9mlraP.P/atarY{t+gmtrcgv aa�r�aa:z� ara

Well Driller Self-Grout Cordow4do"
Owner.-al
I hembZr cKtIfy that the o ovi�rdemced wall wcogmwd is appemmce In amordioce vAh
all Count rWell rules
Welk lhi l My `!,J signal.,
C-morucdon: Type 4 xmcal,
-