GW1-2022-10421_Well Construction - GW1_20221116

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FRO,\r TO ULtNIFTER, Trttt.'tu"'+TEss hrATERUL
2.Well Constr o4irtn owri nit is 3 TOC(t, 15 ft 1" in SCH-40 PVC
tiat trPT nnpt'ficrihTe iertt pr¢imitz fi:r.",,G'atmty;�SFrrs�;.lrnriraRcr,lrryatilrar;crr.7'
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falGeothenmal(HemngtCooUng Stq) tY) Mvsidenrial''i'ater Supply(single) (t fG<
01tidustfl C6uuiiercial [Residential Water Supply(slkired) to GROUP
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itn].elti[o"<Well:,
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5 tL 10 ft. SAND SILTY MOIST TO WET
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Seymour Johnson APB r4 rt ,d 1 v 2—
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1050 Wright Brothers Ave., Goldsboro, NC, 27534
P]ty3xn9,�ddress,Cdk� wd2ip 21:Rlt6rAkIC.'4 -� �„f�ta: •,•� �•
Wayne BENTONITE SEAL 11-13'
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cif.I ffi(irde aril l nnotntic in dCrres}rirtnutcslsccands r!r teeiriial cle rix 22.Certification:
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IN w, 8riam Exi 10/13/2022
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rxpwrrnrrt k@2P nnvcrRs'atxreiin ac v tJic 8rri njtf�ds forat�. 23.Site Itiltj;ranforaddltional wiill details:
You nia} use t) back bf ihis pale,to p10c 1de addi6otial will site, r well
Rainrtlhs r of siell3 CoustrTlCted: 1 Consttirefiolt dei216'You:rrta alsd:ait iclt additioriah pagr tf taccess:ity
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s�tN�?ralar.=,itiirrt; SULINHI T'ALINSITLICTIONS
" .24* For�lll NVillsi "STihltit this farm�t7tlain 3Ct la :aftro IciTgt 'tTf well
q.3bt:T1 Well de pih bdlow Land suvfaC.r. 25 (f1.) }' tnp. .'
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10;St:atlC as tcr.lai°tC iieldra iap of aasiq ,- (Iq i DIiON ion of Wmt&r Re.46u kis,lnfilrmafi in I rrj'esiinh Unit,
tJtrwii r ds!vrT 7�aauzie�e esu'sila�: ;'�" l617 I4laCC.Scnvee Clentcrr It:rlr:i�+,tT,YC 27G99-2517 '
11,Rurcholc'diamctci: (in) gala.For-Inlafil t Wefla ONLY,s In addition to sending dia form to dw address in
24a,60e also sobntiva,copy of this.fonn Within 30 da};s'of Coulpletiau of t%8
12,VC111 mustfuctiou inathod: DRIVEN c snsitriclioiti to tl follu«i(i�:
(i .aTir�r.ragas} cnbir dircLt liusta ctc.} Division of Water itcsourres Undc Lind[ ecilun Contrail Prog-ant,
FORNYATER glbopLT' YELLS ONLY 1636 Niall Sert'ice tenter.Raleidli;i i 276"4636
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Also s<iGnnt u Copy of.thts fotna�sctthieC_�O ili6ofconTplgtionof
�1 1T.Ui3infrYttun.#vp : A�tlnuntr vmli constmetipn to the cannty hcaiih de'pa"m�t of the ccntno°wh=
- - coostnutcd,
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