GW1-2021-01708_Well Construction - GW1_20210322

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VVE L CONSTRUCTION RECORD(GW 11 Forlmanal Use Only-
i.wen Contractor taarmmlom
Gary.Thompson 14.WATMZMM
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ladustrw Commemiei [31laidentid Wow Supply(dmrcd) -iLCROUr -
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A.Date Walks)Completed: WellM# /s n- ys R ieo
SL Well Location: �14 n'
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SL Latitude and lonotode in degreu(miantedseoads or,decimal degt .
Ofwail add,one waano ia someaer) M Certification: .
�be1S'al• lG S�" N kale 63 O /• 85 u
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6.is(are)the vren(aPermaeent or ©'Temporary s' of .w Caotmer Don
t.�9(/ BY a9W8 dmJbm.I h"TO CM&Am ate welt um OMV)caummaad m aamdwta
7.Iathlsatnpelrmunadanogwen: ©Yn or 20-10 ddlSA NCAC 02C.0100 or15A ACAC 02C Man n'ea Cowmmwa 3adendr and Oat
irtl,trbaxpotr)almainmm Well owmnenowAabwm cWgfd,r ,dhmhemproWddmdrud/o ..
nplrendrd21 FAM*amdwiwas deko3q(rkrhaa 23.Man diagram or additional wd deaft
. L ForGeoprobdMP7'or Clased-Isop Geothermal Wank having de some You may can the back of duns pegs to provide additional wall site details or wall
m only LOW-1 isaaled imdkM7UrALNUMBMofwdb construction details. You may shm smah additional police ifaccomery.
drilled:*
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9.T W wellolnekw depth below llApd and knuer `��' fit) 24a. For AR walk Submit do fare within 30 days of complains of well
Frmdgde Wtr/Maffdepdstfddfitwa(ample-9®200'ad2�/00') onenucoo,n to the following:
It Static water level below top dcndng- S� (fL) DMalon of Waar Remorm%fofora atlon hVemsing Uaf4
flmmr/eoda•atwearft are 1" 1617 Mug Service Ceabq Raatgh,NC 2789-1617
1L BmWale diameter. (IR) 24L For imlectiom WeRs: In addition to sanding the fam to the ddmss in 24a
12 well omstntctlun method: t'dEla r A above,alm submft one copy of this form vdthm 30 days of completion of well
fi.a.m r,romy,calk.doectpmhstet _ construction te the following
Dtvlsioa of Water Resources,Underground Injection Con"Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-I636
'13L Yield(gpm) l�rt Method of test e5} 24a For Water Sanely A Inialbn Weft In addition to wading tle form to
the addram(es) above, also submit one copy of this form widu n 30 days of
13L DfsinRetioa typo L �D%» Amount: I G-�z completion of wen construction to the cowry health department of the county
where MnStrrtcted.
FomGW-L Noah Carotim Daps-emntofSmimnmamol Qmlitv-Divisionofwiwlta grAsW2 2-2016