GW1--03756_Well Construction - GW1_20230602

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d.bate Wells d�3 Remetlts �-TTl To ate„ iaei„' =;-=s3
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G �/ N 22.Certification: • .6 g a- a
6 Is(are)tneweII(s) pmm� �` y�
ent or Tea 9igmtmec = a✓
• Is this a repair to on Gxtsiing wens �Y� or� Well Comma
failst Yep frtoldOD ls(fd Pam'- twill Bl'+tlJ4)duijvraylbae Date
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r' 'runiter�Ireae,I�recria,arona ��°smnaudmplabr the tmtm�elrlu eopyojfdite �mad 422 e �IJANG(CDIC.6the ��700�lCeetta anunreted Si drd0inx
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8.For GeoprohNDP!or ClotedlLop Site du pro,rdarrotllct:yr
construction,only l GW-1 is P 01�Wens having gram itionalwendefogs: •
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drilled needed.Indicate TOTAL, g1lta8oma You use the back of thia
�R dwells coastmcgondeN►7s You maysatta provide page to eddrittonsl p l site details or well
9.Toot wen depth 6elprryvIdsa facer 11'7►r ..,,r__._ °teary.
Form,+lay[eadts/rrtafTdyuhr • .. C1 an
"Ill statteev erIniter aidsreArl Way ( t.3a20 2�tL0. Ju) 24a. a 1 e Submit this form
• ifwaterte,rrtratevecry;egare top �G eamsmttetinnmthefollow,D widen 30 days of completion of well
11.Borehole diameter. (�) Division of Water Resources..Information Processing
— (Ip,) 1617 Alan Service Center,
12.Well construction method; in
r Raleigh,NC27699_I �A
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e soar;may.raWti dueetpmh eta) ? Y'j i( above, �� � t�°•°o the adds=in 24a
4R WATER SUPPLY MILS cOostmcdon To the I0ll°'°;� this days of campktiom of well
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13a.Yield(pt,n,) f- D` m Of Water Resources, •
��� tlad Water Reno rce Underground(Dleedott ControiPrograra.
gorlolhsf: �,r/ Centei;Rateigh,NCa76gga6i6
13h.Uiatakedon type; i< 1* r water �Imreettom wan.-
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Amommt: Ct%' address[�l above,also submit in addition to sending the form to
completion of xall construction to the copy he this epa r Wort days of
FarmGW 1 N where constructed County health department of the eo°arY
aD °meant Qualify-]-Milian of Water Resources
Revised2-22-2016'
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