GW1-2021-03325_Well Construction - GW1_20210603

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WELL.CONSMUMON RECORD(s -1) For h*mial iTse€}aid►:
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(ClosdLoop) Tracer 2&rZ8��GiM-' �cfh=dz�afotheamal(Ileatinglt oolm-91Wttua) 00therfaTlarn urn#'21 Ream) D ^area s�:r� pact
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4.Date Wetl(s)ComVletd: �� � �*'e11� �"� 5 E � G R g QQOwp SraN G i/3
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6.Is(are)the or 'Semporaey Sig mm ofCeftiBed Well Cnna=tw E?ate
By sigrr."ng rim-.far.+r,I Ir..seby sera-ty rh�t rtr x�fs)x�tour)ean�ed;n arcard�
7.Es Obis a repek taan exisfirg wren: nYes or dNo with 15ARCAC01C.0160 or 13}_h'C.-+_C 02C.0100 Wcff ConunicumSfa xav&ar<d USma
Ifthis it a rrpair fH ow kwtm rdl eamtnwr wfcr.=afton&dcgd yr ex n=ar oftfe copyofC-&m ord hn hem pro-vi*d to the=a ora>?
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23.5atD diagram or additional tveIi t1etAls:
S.For GeoprohelDFT or Closed—Loop Geotherinal Wells having the same You may use the back of this page to provide additional well site details or%veil
constructioc,only 1 GWJ-I is neded Indicate TOTAL NUNMERofwells construetioa details. You may also attach additional p2gesifnecessary.
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SUBRM-a AL OMMUMONS!
9.F'M&If�deepti&&t fd9bdw if sabre: d �For All Submit this form vein 30 of Mo. of sill
1�Dr r77tdffp w r 16r>s11 f'a+. ,+rtes pte-3420p'�,d�@1ap? ) construction to thefbRowing_ � comp
Mon.
Statievaterlewd below togs o€easirg: QL) $aCt i'Yater; a' i
Ifzraterlefrtisabacrcal%rimea4-" $ lnformstion glnit,
(t 1617I4 a Servie a Center,Iaak§,NC 27699-1617
11.Borehole tliarceter 24ts For Iniee#on We Hs: In 'addition to sending the form to the address in 24a
It Well a onsbmcfdu methd: LA!Re 91 above:also submit one copy of this form viithia 30 days of compie4wa of well
(L-—er,-tsry.cable:,dicecz push,etc) consnuttion to the following
liivision of Wete r Resour ce,Undeeb ennd Fn e eiian Control Prod a@,
FOR WATER SUPPLY WII,LS ONLY1636 MaH Spice Center,RaleI,NC 27699 l636
13a- rrdd( m) Method oFtest 24e`For Water Sesmuv&l wfiloa Wells: In audition to sending the form to
the address(es)above, also one copy of this form wifirk 30 days of
13b.Didlnfection type: Amount: completion of well won to,the county health departrucmt of the county
ivherE cmnstru�d. � ,
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Form GW-i worst:Caw ma D arm woo,,-,..•,-J Qmrty-Dzv=n of wztc rl:esotesrs Rnied2-2-2016
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