GW1-2021-06687_Well Construction - GW1_20211007

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For Inttrnai Use Only:
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Well Counclor Name To
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Sb.Latitada and levg rude in degreWminatas umuds or decimal degrees: _ J
(if welt fiel/df�ouaz�w0om$is suEHciaat) 22.Cerdfimdon:
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7.h tbk a repair to an e4ftg well: Dyes or Opo i*h l se.NCAC 02C.000 ur Ica NCaC 02C.0200 Well CoAroucdon Sumdardt and tJwt a
If drte it a repair,jiff ow lamwr well eowb -Hon information artd explain the na+urz of the copy qfd+is reconJ has bs n provided to At%wit owirer
r qmk Radar#21 rmm*ndwn or our d+e back of fhia form.
23.Site dhtgraam or aAMdonai well detailk:
8.For Geoprebe/DPT or Clesed-Loop Geothermal Wells having the same You may use the back of this page to provide additional wen site details or well
c onaPtuction,only 1 '-i is needed. Indicate TOTAL.NUMBER of wens construction details. You may also attach additionw pages if necessary:
drilled. 9UB:�91TT'AL INS'�UGTlONS
4 Tmfal well deptf below bind ent4aea: 24a:Fa a Submit this:font within 30 days of c-ropled- of well
Fa ewlt(pte x�ells Llet aJi de�rtA*(/�f�rerta(s:aegple-3(a}2DO and 2(a 11)0
on he fonowittg:
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1617 A9$i!Sers+loe Ceentar Rraklgh,NC xT699 161'f
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1n addition to aenAirg the fnmt to the address to zee,.
! orno we.
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- above,::also sulrrnrwrnle cc�ry�o thief 't 30'days f oaiplbEi. "'f ll�
12 w�i xetlan mmttiod A L construction to the following
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FOR WATER SUPPLY.®VRI.LS ONLY: bf Retii►prase,l3n&�rgraund.lnjectlon Conirot lPrugr ern,
1636 AqM mice Center,Ram.NC 276"-1636
13s.Yield(Um) Method of teat: lac-Fbp W$tgr &aennty dt In addition to sending the force to
the address(es) above., also submit due copy of this fermi within 30 days of
13b.Disinfection type: Amount: completion of well construction to(tb� county health depitmne,nt of the county
wherexnstmwwd, 1
Form ow-1 North Camlioa Depwftwt of Eavuraumial Quatity-Division of water ltwourm Revised 222-2016