GW1-2021-03809_Well Construction - GW1_20210823

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C;enuy PnreelfdomMeation No.(PINi
51).1.4tilnde earl►onjolodt in dcgreegpdantesfaeconds or decimal degree s.-
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ti.Is(are)the vrtlt(x) Permamem or DTV.Mpornry ii erea,nifieu WdtCa„aaatar
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1.' arWtuu3,1,iR form.I!tndro'Wrd'tom die crew x)ma 6-4tmrrartae7arl as otsnrAmne
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is this n teaser to an e:artittf;welt: YCs or too u.id'!31 ar..'pC o2C.-Atop or 15A NCAC o7C.OToo Well Cnnr►ratxfon
t►r is n reim1r..01i me known wdl eonstr,rctrnn i,,�rmatian mtArsproia don nh'nrr nf'ihc copy ofYhh rrcnrrl has wpm prot7cr:arlralhta tveff mutter.
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I'wir tondo A2►ntmarla sesooa arms rfn:hacl•"fill IV foal'. M Bete dl*xmn or eddM=W wall daetlla:
R.ForGeoproheMFT of Clw&&l.onp Geotbcr»i WtlU having the sm a You may use Ilto UneTc of qr�p9ge jt0 prwvido additionNl well An demi[4 to weq
mnstmetion.only i GW 1 is needed. radioato TOTAL NUMBER(INN lls cptl9Wntlan tfRalls• YOtt rosy A1tta Blench addilionel ptijges tf t100089BtY
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'.t.hotel weRdlepth DQlaw land surlllccs MR. FALA WO- submit this;form vvithin 30 days of compldbn or welt
fnrmn►tlofc�r,grlistafldaprlu'fd(gerreu(example-3ti+�JlJf+'nnds�l+lla09 eanV1f11CilanlathCM101ft:
M.Rlatic water tenet blow top of easingr ___.___.__(h•) Division of Vitaler Romtta en,lntbrwAHOO Pr'a+eess6lR Unit,
(f xmler(earl tr Mvivc t m ag,lac^i i417 Mnff Sarviee C6111 P,ftleigk MC27M-1617
II.11otcholed)ameter: (in.) :Ertl,m,.. a•incHon Walla: in addition to onding the lbon m dte addrow in 24a
/� above:,ciao Submit ore copy of this farm wlibin 30 days of t ORWalllm of well
1211tc11 etmetrneHod metlaad: �'-"'�i ramstrnation to the following:
V c.m qc -M. .cable,oirmt push,c1a1
Rivlalon orWatcr Retltn/rees,Underground injection Control Progrota.
lY7Hli WATER t+t.,'Ppf V WELLS ONLY: 1636 Mail Service cea'uw,Ratelo.NC 2709-1636
134.Yirld 1gp1m) ��.Z NEW,of lase 244t.j?(W wea &iRIWA n WNlit: In Affigon to sand ng the firm to
Me oftiass(cg) ahottn,also submit;one copy of this form vANn 30 days of
13h.111sinfeerian type: ,Amount: completion of%vdl tpnsutraion to the celanty health dg wtoac t of the county
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