GW1--06547_Well Construction - GW1_20231006

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4.Date Well(s)Completed: '� 25 WellID# 7‘ R- tbo� R (L ik.
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:(if well field,one lavtons is au>iicteat) `r v q _ � �p��,�
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3 -- oral:Mei wen Contractor Date
sisaaNm
Yermsnent or In Temporary 6.IS(nre)the wells) orarY By signing this join.I hereby cettiJy that the wall(s)ans(were)constructed to accordance
7.Is this a repair to an existing ®
Yes or DNo with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Simulants and that a
phis is ;jtU a repaG out known well construction information and explain the nature ojthe copy ojlh[rmwrdhas been Provided to the well owner.
23.5i1e diagram or additional well details:
repair under#11 r sect(en or on the badcojtltirjorm.
You may agrause a back this page to tails:provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction deems.You may also attach additional pages if necessary.
eaastraction,only1GW-lis needed. Indicate TDTAL BERofwells SDBIMTYAAI.IpISTR11CTIt)IVS
drilled:
p(?5 (ft.) 24a.lee Alt Webs: Submit this form within 30 days of completion of well
90 Total rmawelllst alldpbelo land surface: le WOO' construction to the following:
For maple walk list depths ijd different(example- °C11
10
(ft) Division of Water Resources,Information Processing Unit,
!j water
f tie water level below tap of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
water level is above casing,use"+" i j
On.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
11.Borehole diameter; above,also submit one copy of this form within 30 days of completion of well
construction to the following i '
12.Well construction method? )
(i.e.auger.rotary,cable,direct P Division of Water Resources,Underground Injection Control Program,
1636 Mail Service i Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY: �j
',- e i.,1 Method of test: "3 .,%ir �.For Water Supply Srinlectien Wells: In addition to sending the form to
13a.Yield(gp®) the addresses) above, also submit one copy of this form within 30 days of
WI'� Amount: 46 I-- completionof well construction to the county health department of the county
13b.DlslDfection type: where constructed. f
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Ferro GW-I North Carotins Department of Environmental Quality-Division of Water Resaultes
Revised 2-22-2016