GW1--04529_Well Construction - GW1_20230713

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• 4.Date Well(s)Completed/ 'p 4 ?Well MN:, /Oa " //? ft /G-'era, Q
52.Well Localism
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- Sb.Latitude and Iotsgllude iu degrseslminutes/seconds or decimal degrees:
(eewa11 field.ono tullmtgiswfIieimt) 22.Certilication: • 4,6 ga- R
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6.Ia(are)thews l(s) Permanent or[)Tearporary 9igasrmro added ell Connector Dab
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dds form I hereby co*that the rretl(s)its Afro)comurctod as accordance
7.IS this a a to an calming DYes or psi"„ with LIAXCAC 02C.0I00 or MIMIC 01C.0100 BreleConDnaUonnStandards and lbw
pis is owes:Jill onassoonwell ourtrocrian II Amnion and taisk i n the naive ethe WPyoJthir^emd has afeitpro1YdtdtO(1wwelotmu*
rapnirmderON mama;Milan oron'ha hock c/drisfomt 23.site diagram or additional well details:
• g.For Geoprobe/DFT or Qosed.Loop Geothermal Wells having the soma You may use the back of this page to provide additional well site details or well
• construction,only lGWlisneeded.indicate TOTAL,NUMBERofwells construction details,You may also attach additional pages ifmummy.
drilled SUBMITTAL 1NSrRtICJ IQNS •
9.Total well depth below land surface: _as (k) 24a.For All Wells: Submit this fonn within 30 days of completion of well
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Flo muWpkIrcns Mall bob['Vows a•3(WD'too IV ielr) eansnuetionto the fallowing
10.Slade water lewd below top of casing: ‘0 _ .(ft-) Division of Water Resources,Information Processing Unit;
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!fume/runr abort au*pus+1 1617 Mail Serstce Cofer,Raleigh,NC27699-16117
U.Borehole diameter. le 944 (lit) - 24b,For inlectton_We14r In addition to scndbtg the 6o<mt°the address in 24a
12.Well construction method: Ap4a4^ t above,also submit one copy of tits Am within 30 days of completion of wall
6.e.auger,rotary,rabic.dtmt pub eta) consaariion t0 the follmvittg
FOR WATER SUPPLY WELLS ONLY: Divufen of W ter Resources,Uadetgroamd tnleetion Control Program,
1636 Mail Savior Center,Raleigh,NC276991636
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13a,Yield(gpm) R'O Method of tell: T`�rl/r. —4 ?+ter For Wafer Sunk&Infection.Weller In addition to sending the fonts to
/� 1 ! the addresses)above,also submit one copy of This form within 30 days-of
• 133h.Disinfection type: r/S!r Amaunn 3 C � completion of well construction to rho cotauy health depamaent of the county
whore constructed_
FarmOW-I North CararbDepa,rmeatarEmd,omaenulQoality-DivisionofwaterRcso>arxs
Raitad2-22 2016