GW1-2022-09332_Well Construction - GW1_20221007

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REMARKS
C—ry Parcel ldeori&aQonNa(Pug W
Sb.Latitude and longitude in degreedwiuntestsemnds or decimal degrees: -
fifwell fic1d,Coe lavlongis safiiciaa) 22.Certification
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S"`is(are)tltess){s) etTaaaeut or'EITemporary Srgnaiacc5. ed•WellContractar Date I
try aogog.ms jarm•r A f hereby e�JJ•that the welt)xru uva)mnsrrvetaA In accordance
T 13 this a rep:it to an azis6iag well: ElYes or oNo with J5A NCAC 02C.0100 or ISA NCAC 02C.0200 W II Cotutnrction& datrls and that a
ljtbit fs a royal•,Jlllaalttoaa xrll tmrr�affoa tnfmmet, mrd ezglale thei+anve nfrhe copy ojtias—ord has bent p wwd-ta the xrll aanr�.
tepair tinder o21 reaarb>sectbn area d eb adcojthirjmna 23.Site diagram or additional well details:
Sz For GeoprobdDPT or Closed-Loop Geothermal Wefts having:the same You may use the back of this page to pmvidc-additional�vef site details or well s
conduction,only i GW-1 is needed.ladicetc TOTAL NUMBERc fweus construction detais.You may also attach uldit oriel pages ifnecessAry:
drilled SDBMETTAL AVST tfiCTtONs.
9_Toisl sveil sir¢th below land surface# 18S ( ) 24a.For All Wells: Submit this fbrm within 30 days of completion of well.
F nml>SPIe wrlla ref ell depths jr6�QaAr(eramgk-3�zo0'and2(}rOD j construction to the fallawi g: �.
I&Stxuc,%*ater leyrl,bdowtop of rising:- (ftj Dh4sioa of Water Resources,Information Processing Unit,
joule loved ra aGoce acdz uar 1617 A7eiL Service C®hr
�j +Ratelglh,NC 27699-1617
f Bafrehole d r. _ "- �m3 24b.Forfnleetion Wells: In addition to senil_ue l l4
r. above,also submit one c of this-f gibe form to the ad in 24a t•
]Z Wels co,wh-gun metfivdo orm within 3Q daysof mpletinn of we I canstmdian to the following:
(tee.,aogtS tataryt cab?q.tluectPash,'�c) ,. -
Division of Water Rewnr s,Und f
er RRIdd Injection on Control Program,
FOR WATER SUPPLY WELLS OP(LYz 1636 NIaO Service Center.Ral - -
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Ain.yieldtgpm) iV dh(td oftest:'" 24r.For Water SL�+�Iv&Iniacdon Wells:
:. die address(ea)above,RISO Submit one c In addition to sending the form to
:y3b if5sivfectlon iyge Auto®� eotupidioa of well conskuctioa to the oounEy oealth deptunnent of tlteimtf!this form,vVithin 30 days y Co
whttecoostructed:
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