GW1-2021-05782_Well Construction - GW1_20211015

SELL eONSTRUCTION RE �rGW=11 For Iitemal Use Only I-,,
L Well Contractor Inffoo]rmation;
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4.Date wen(:)Completed:lD—/!-d1/Well nX 1S/y Gl/ & &
SL Wen Location:
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ComnY Pastel Weori6cedoa No.MN)
Sb.I.atnsde apd 10aghade in degrees/minutWseconds or decimal degrees:
cxfweu&K ace wim a=ffideat) 22.Certification:
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7.D this a repair to an esisdag welE' •MYns or tiff o 15AAr-4C 02C.0100 or ISANC4C 02C.0200 Wed C4ttf t:ffw Sw dw*and dnr a copy
Ijrhb ba,�atr,�d oaebivwss wrll avamru7ar nJoromio>r mdasplmo-r rhe,smas ojrhe of#+ts raaavdhas bmt pranided m the Bred awa�r.
tap�i tosdri#21 savrmhrs marmt aran thebanFojrhfsfmsr 23.Site diagram or additional well detaft
S.For GeoptobrJDPT or Closed-Loop Geothermal Wens having the same You may use the back of this page to"provide additional well coosaucbm info
comftuction,a*1 GW 1 is needed I6&cie TOTAL NUMBER of weft (add`See Ova'id Rem BoxI You may also attach additional pages if neoma y.
dulled: 24.SUBMITTAL Il�ISTBUCTIONS
9.Toad wen depth below land surface: A) Submit this GW-1 within 30 der of For aadapfe,.s&&I ad dWdr s f&ff& (a�plr-3@200--mw,d2@100� days well completion per the fenowbW
1Q Static water level below top of easi /ng: 9, (ft) 24s. For AR Wells: Original form to Division of Water Rasaaees (DWR),
Ifwnmv lepata osvar -f. l l Iatn;Zm Proceming Unit 1617 MSC,Raleigh.NC XM99-1617
IL Borehole diameter: /a {m•) 24b.For Infection Webs:Copy to DWR.Undagrnmd h*tion Cowl Wq
t Program,1636 MSC,Raleigh,NC 27699-16M
12.Wen eonsft ctien metbod: 24c.For Water Sang and Oaa- Gcofhermah$etas Welltr Cagy to the
C—�-M3.�&eetpwk eta.) oa+mT euvirmrmea�l health depa��t a coa�ty wTm�
FOR WATh3R SUPFLY W&I,IS ONLY: 2"For Water Wells reds' over&00&GFD:Copy to.DWR,CC cUA
I&L Yield W* s Method of test a 1 r Pamit Program,1611 C, 11
ob.Dlswieeton type: T f} T Amount:
Foffi OW-1' Naaih Carolina Deparmzew ofFavatnm=caI Quality-Division of Watcr Reso=es Revised 6 6 Zp1S