GW1-2021-06909_Well Construction - GW1_20210505

WELL CONSTRUC HON RECORD(GW-1) For wand Use only
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4.Date Well(s)Completed: a Wm ID# 1 � ,. a c� R 5S n Zp rit_ . ¢�
Sa.well Location: 5S ML Sa- 5a fAAA+
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5b.Latitude and WmgRude is depecs/miautes/aeeoads or dell degrees
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6.maw)the well(s)iQPwoument J j or (3Temtm" Ofowsed Well Oasmaaw Date
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7.b this a repair bu an eslstlag well: OYes out tallo wfdr ISANCAC 02C.0100 or 15AWCAC 02C.0200 Wep Cavts&ucdm SWidmds and due a
lfdds Is mpa r. ll art browny weft oaubadfant bfonnatfm and amain dw mamma afdra copy afdw rwar dhm besrpmvkbd to dye wW owmr.
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&For GeoprobdOPT or Closed-Loop,Geolber al Wells having the same You may use the back of this page:,to pawide additional well site ddw3s air vMU
cooftuction,only I GW-i is needed. Indicate TOTALNUMBM of wells cousbaction details. You may also st<arb addidonal pages ifaeoesmy.
drilled SD>1M17TAi. i��ON3 'j
9 Total well dghffi below land surface: B S cam) 24m.For AN Wells: Submit this 1hrm widda 30 days of oampietim-of well
For mrldple weds 1rsY aAabpdu ifa6�pyerS(asmrplE 3®100'and 2®100) eonsRuction to the following;
10.Sbdk water level below top af eaaiag: J� 0 (fL) Dlviaba ofWater Resou'rem luftwo elm Proee0bg UNK
if aWkwl babove ar-}- 1617 Mall Service Center,RaIdrgh,NC 27699-1617
iL Borehole diameter: b (in.) 24b For Lieedba Wells 1.addition to sending the fog 1.the address in 24.
12.WeR ceostroetim method: 14 l�- 1�iTY? 1 move,also submit out copy of this fa within 30 days of completion of well
C �may.� Pam.�) oonstrudion to the following:
Division of Water Resomoes,Undergnmud bjeed-Coafivi Program,
FOR WATER SUPPI YrrWEUS ONLY: 1636 Mall Service Crater,Raleigh,NC 2709-1636
13a.Yield(gpm) OV Method of test l 24e.For Water S®Dly& WeHa 10 addmoa to sending the form to
"� � the address(es) above,also submit me copy of this fans within 30 days of
13b.Disiebedian type C C.V���r'TP.A t a 9 Z completion of well owstruction to the county health depaltaaeut of the county
where constructed.
FGMGW 1 Noe&Cason®DepstmaatatEavusmaCWAQmddy-Divitionof'Wawftscan= Revaed2•Z-2016