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GW1-2021-03704_Well Construction - GW1_20210823
• a2a»822h?2�1 I c-A) 15 1:9 05;43p Clearwater Wall Drolln9 •r•r�•"'t"' wg&je ON � RT►cg GVV-Ji.) ForTnteM01 tan Ix. t.Weil t• • _— (�nt�rn�n�m•1nf211010. .'•L• rtl Cnnrnnnr Ceetltirnttnn N+rtnikr• � � Q112b1 251a food 4-AMPmi-Namr ..& 5� e �► x.Well Conxrroettrm Permit P. . 1./crnr1 nP141m /r wyamannrarinn pnrnrllr(Aa.lilt;OOMPI S&TIc,:fal O-0,N«1 3.Wvll USP(cheek w it ttsej; Il•. � to' tiYq fcr,Sap1 r Wtil: AgriculturalNlmlinipaUPuhlic 1� Ar, r h, C'rcotnrrntAi(Heating/conifng Supply �Rw91det71(a1 WAterSnppty(tingle) fLta, 71 rndnarslolleommemial DRaldcntiat WAier 4upplY(tb"M) irtt�oAltm._ 7• za Nun 1'1 nttr:iairpty YFet►: ��-��� n^ �' � �. AIORitorit►g ©Recovery p^ Agnifn ftecitttt�r tl, R, �Ctronndwnfct(tcarrdislinr ntptifrrstorapennd , (IVery DSnlinity 13ntxier Agttilc:Test [38mmtAytitaDrairmgu rNperirnentat TeelnTORMY 'Q5nbafdenee Control 0- ft. C-Ofhrrmal(CloW Loop) Q'fMM Ilt1. J- Geptdcnnal Heatin Capl{nglkmm��/'"JQLer�exptnin War M..) Rermft) ff, � i,'I Well(a)Coaapiat.mh .__._� + Well li»E, - _ �-ft. � 91A&�k _ Sm.Well L matnone 'lrilif•V.'bM �;Cil@y(i)il(sfJgljllfngblr,) #t. --- �' ,;�', --- t't tiimdArtrlircrr,Chy,�d7_tp .—'_ 1T. R i�rr.,E`�SSC J renmy iMrxt tdronll coition rim(A1T) o it>.t,gtlnnde omi tonRltade.In degrem/mien t0secnmlcordecimal Airy rRec; -r-------- rii wail find,onq Inoons in mdllydrmt) O t lion; r•1t(arr•)tfir well A 0Othfrirnd ei1Ci�Ittraelor l�G 7 ( ' 'ermnrnent nr �17'rmf►nrnry 717)MA � %•tt fair A.repair to rtocr3 ag e11: Invos nr iSQNo W.;ff.'07 .?tafl or MA MCA C..920.0240 Arrdl CmW,vmmr SnvWgrdt mnI/liar., y'rbt,•1x»rrrR.ifr,JUlmrrpnnnmsoAtlrmnsrrncllvnJ>�rmmrnn�td"rrprrmtll+crxur+rrnfrhn enPNnflhter+:+aorv►hnrbtatlprinNd2tAmteewCilmvllr�: +::pair rmdrl•L?i r°mnnls.YarMrt orort 1Dr.h/7rj,•njtalxjnrnr. ;t.�,:die ortafNMtigntd allll dMUlts R.liar GrvspraA,.-4)F 'or 0md-1,oap(,eoftrnmi Wkiir hnving the same )0a+u may oon file Imck of this Sop to pmvtde addtitntnt Avail she delol)t nr well /xrtwnrrtinn,<)nly I GW-I is needed. FiRU t+t TOTAL NUMSFR of-mrlls �s9tructtnn<1Kaii9, Yete tgay s}an Igtaeh adtliUonal pa$ec tFneaeaanty. 9.7`11al well depth Imlow land altmec; 1%urn+�ldMrwallrli�rrrllA,rPlhei/e conolt" i(mtotheM1011ft�rmr(mPmpim.rA1#V'nnd:(r/01t��-'" A14 744• P"' lm.. Submit III flsmf mihin 28 ales twoor fletlan of well 10.RtNIFr,tvaltq•(evM below top of eAafng: Mvlalon of Ylrotm•Rerlanreee,Information Proea ft#Jain, !I a%/�/'I/n'/rl ll•I/l7+lY!CYrridR,DAtt�•" It_ ( C 1617 Mall Slerrvlce('eater,lMiafg,MCa7*Wj617 Rnr+eDMedltfmnMr:�,______T_(In,j 9M.BIN tt WRB lYeflm in addition to;lrending the form 10 ft nddrtala in 240 l�#Veit conitrnetion toblhod• aheve,tips saRrllntt One 00"of this fbrpi+v11Aln 30 dW. of emapletltrra of well ""Mr.mtnm mmo.dtme4 ixtsh,etc,► �••••-,, ronslextion to the fatlnwina cote WATrR i4l,Pl'L li WIi l g IfNL Y: --AIMMOn of watsr Remroek Ulmer MUnd lVm*a ConfrM PxMmm, f 1624 MAfl S"M Co ",Rmw .14C"WA-163ti F 3a.Ytrld(Rpm) Ma�tltral of temk C/ z fc.i7m water sonsly A i<ofsoNrtn Wrn� to addition to sadius the(Firm to ran.hrsanfccrian r)+Ira; � IRmmti me nddr�aa(es) Abner aisa arabruit 'me ropg off'I1110 form Whilie 30 nnI of coelpkiiar,of Alxli AelFttftlgion to the ctprniy Imam dal wmm of the 1;m1111} F na�:u.•..t v1""tegktflltetard• •--- --•.-.----• Nnrrr,t�mNanDanntm,enr.rfth,�/cnmm�neniljm+tlN-1?lalsmna?,'Mprer'Rnaottecae Well Driller Self-Grout Certification Frees Address: �Ot S��,n a s, NC Q'�'I43 Repair: Permit: I hereby certify that the above referenced well was grouted in appearance in accordance with all County Well rules. Well Driller: Ql� VA,60(6,tz,`'�S Signed: --- Certificate#: 9 t 13 — Date Grouted:— 3 �' Construction: Gr ut Total Depth: aS Type: - Casing Type: 5 �� Thickness: Casing Depth: Dept,: a 0 Diameter: Weight/Thick Height: Drive Shoe: GPM: 1S j