GW1-2023-01123_Well Construction - GW1_20230126

WILL CONwmur-nnw FORD For itue�i tleaONLY:
17int tbrltl atn be toed tbt Angie otmulttpk�e1L9
1.Wdl t3eatraetar IaRrttpttllpm
,loch Plemrnons
Well tM�darNetne• It �
4137-A It tz
MC Wencottmiotorr,�gfl9ntOaNtnnber
ClsanwUr Well Daling lnm a y tt le.
Cen�uty Name t
tNA
2.WdlC@asV=fM paInk#, tt, tb te.
LcaaNapplycrrbk xrll ae►nlr�ttrlos perntJte(!a Cotmp,91ura Y d� R IL
3.Wdl the(d"k WA mek
Wntn.tl-p W.lf:
OApJ=M nl yp yn (G R 1L
O(leetht rma(RawthtgVOdjnB�PPh') aidmuGtl Wits DIY(dnl e) or. R h>,''.
O F�paM oReaidetltiel Wita SnPPh►fs6aed) ROMER
olM
1'N�Wttt�SttAly Wdh � R'
OMoaitoria OR&wmy n. a
8. R.
OAgni fw Redwso Rruttedimion
C1A"ft Storego end RecavMy dgetittity 13mter
OftuiRr Tea *' R'
C13tormwater Dndttttge
M sped nwnl Tedmana ClSuhaidertt a Control IL' R
oocmb= tl(CIMM loop) fa7lacer
1 Reluetl -�l30dw lsinttnft*2l Remarks IL IL
d.alakwds(i> ,td1;IQ"�- I►dilDd ,< d
nL `py ar.
sa,wen lweetlipt;
". 0
� PBdiltylDO(ifeppliae6te) w. R. ,
�'t'e�e t�rotr�ade to dt�eetlstfeutee/t�artds ttr tkehel ttegteea: 22.C
O�t(ihaell fleNl,mte tetllttng is>e ``��q ((��QQ `` ii ` '�c�
�� �JN VU�t��1', `�tJ,�^q► vL. � I� f V` p(���
sl ofCftffadWeSt of
b.1e(tare)the WWI):` or Me"Grary
+cigntas fib,fom,.1 Ae".v-w0 A Ibe.ae1!(aj uw t►wrJ cmnnwAW fk
etltia l.7a�r man�)iWell. pXea or **k15AN art
CACO2C.0100or114MCVC.0200fromCp MdM,7
a tre a�yofthlrrner�Mbmtemprovlld�dwrAr floe�wr.
�qrM,�llcvtAansn�x�Jc+ornn+�citenlltnmtMAQ dwplaleMeR4Afieof/he
'°�'•••�ate•rsw+ra►.geer/araranrA�.e�oatq'ohr,.(o,,,. 23.4MeiYearaat aradiMtta+l�tl�eli dwllR
af.Nataherof �; Ytm OW the the heck Of thR page in PF&d&AddltlMM WM fib d&VA ar%Tjl
�"'' °I'��er 's�lyuelhntArtv,aNhrAr�.,araae�a�to oa�tcnctiondetet7e.Youmayaboat4chtldtgtfomlpl�eslfnCoeewry.
,ee.►rroaa2b,,,,. tR,►mr rmt
rr nn�•— gAlHililITTAL INAiTlJCIiONg I`
9 Ted!t dRlnl helolr brat!t+rafieae: W t� days of ootn of welt
FfN�atnMlpJeNnRoJtetolldy�P►a{/d ar( Iz`3( (pi'mrd2(�Jalo`! fh) COMMMSMtOth fbjkRVkW t t1dS l�Inn;Wllhin 30
l
t"Oftk rnarle CMft.Mef.+otemmg: lam) avl.lon.iw.terQae�jr,4taebr�e. �i
r""�"�'bA�'01r"��'°+"l i617 MiN Selvlel�'I't�.:tlii�ll,NC276il1�•iii17
]1.RaNeledhaaeter; (5 ) 94b.f or inleefw Wei: in wMitla.40 sendmg the Run to tht:eddm a in 24a
14.Wee mean rncl above niau Aubmit aopy c of t6 fbmt;wltbin 30 dipof cotapledm of well
f°tmgey romry,aablgeetpeab,eto} { V cotmtn>ction tnthcfblkfwing: �,
FOR WA'1'PR 1Dtvbien et Water Qauulty,vmwrymtatad tee Ct
SUPPLY WELLS ONLY: Q 1t536 tMrtll 9crvtae CBalea,Reklgh�,NC x'16b1-1�6 "Oy
131a.1fWA(Rpm) � Method of teal: il.L` 7A� ' dddHian to 9endiag the bhlm to
lab.Dhlafeef tkc eddrcas(es)above,also submit ate copy of dlis foltn pidgin 3fl days of
Amour. completion of wdl Consmwlliln ro fire txitlllty heahb depzdulmam of dle county
wirero conmructed.
Form ttVl►t Nntth Catoflna p°Pa�Mt't'D�vGenmea aid NnteratRecautaa_blvtstan afwaterQ�uliry
ReAWJan.2013
I

i
i
it
Well Driller 5qwsmat C*Mflcat m
I.
� ill �-Wea: �
Owner: N
�1 T
Addrew.
PerrniC,1�t Gir�ln C 13C.,
I hereby cadify that the above refeMCed ma vas grouted in appearanCe in aaArdanae with
all County Welt xvles.
Well l ler_ 5 Sig-real c 1
Groutiad
Certificate#: Da: '_ � '��'
Constxuciiorr Cold:
Totd DqA: �9S
Casing Type;�/C�, TWIcness: [Yl Q
Casing Depth: of ��tlt: 01�
DiamebarLia r_
Drive Shoe:
UK Q 0
i
i
�I
I