GW1-2021-06458_Well Construction - GW1_20211022

WELL CONMUCHON RECORD For lanerad Uro ONLY
Thb farm can be used forsfiq0e ormnWgde wals
1.well Contractor Information:
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2.well Construction Permit ft & &/ R " I- I S e,.t +z "
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oAquiferStorageandRecovery OSalw4Barrier J tt 6$'' R P art(
OAgiuferTest OStmmvraterDrainage
OFxperimental Technology OSubsideaoe Control R fL
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OGeothamal(Ctased Loop) OTracer FROM TO »ESCRWnON ceba mWgeek
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SIL Latitude and Long tude in d atesfseconds or de dmal degrees: 2L
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6.Is(are)the wel(s)c or. OTemporary By 519arrg ddsjorm I hereby ca y#dmr ds weg(s)may(mere)cmnamed fn ar000ndm oe
vuh ISAArAC 02C.0100 or ISA ArAC 02C.0200 WcU rvn&Vnc6mr Slmedmds and dmr a
7.Isf&arepbh to=edslingweR: Oyes or [3NW aapy4df:saou AwbeMpmrfdadeadxwd1Ow er.
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repdrmd2r021remohsecrfwr ororde back ofddrf— 23eam�ad wended
You may use the bade of this page to provide additional well site deters or well
R Number of wens contracted: construction details. You may also attach additional pages if necessary.
For 0aftWe h#w am orOws-m rsrrppdywel&OArb rW*dos®ravrsbmefma yvacan
sabmir 0sejbnM SUBM]TTAL INSTUCTIONS
R Total well dep1b below land surfaoc L (R) 24a.For AN Webs Submit this form within 30 days of completion of well
For mddpkwe&1hraffdqwhusfdjF--(—mpfN3@WD'ao d2@1M construction tofhefollomi ng ,
10.Sta4c water Ind below top of easing: Z 7 (it) Division of Water Rnowmes,information Processing Unit,
4rs rerkodIsaboveamft nw 1617 Mad Service Center,Ruldglr,NC27699-1617
IL Borehole diameter. i/ (m.) 241L For Iuieetioa Wens ONLY: in addition to sending the form to the address in
24aabove,also submit a copy of this`foim within 30 days of completion of well
12.Wen conlraetioo Inan construaron to the Sollowing
(Lc.Mtm.army,cablttiaaeex Ptak es) Division of WaterResowo6.0 h*ctiuoCentialProgram.
FOR WATER SUPPLY WELLS ONLY: ,,,D 1636 Mad Service Ceuta,RddgkNC 2769 406
13a.Yedd(gpm) Meted of test�11 Al 24e For Water Supply&Iniectieu Was:
Amowwt: / Also submit one copy of this form within 30 days of completion of
13b. ty.��j�j,� ��� weld ion to the county health department of the county where
FareGW-I NorthCu*UnaDqaea=c tofFse.*==daidNamalRmm=m—Division of WaxyRew== Revered August2013