GW1-2021-04104_Well Construction - GW1_20210823

828-622-7241 p.1
Feb 1519 05:43p ClearvuaterWeli Drilling •�•••�•"'
WELL FeMEE U .TION RE-Co�.D{GW 7l)., 1?ar 1nRtxnal Use nly:
1.Wr C Intractor information:
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2.Well Coom-netlon Partial#: t, ft lit•
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5,IM 1CtC(check wrl)int): 17. irlliC flee CAL
uVatt:r Supply Well: re
Agicukural omunicipol)pubk to
eatdentaal Water Supply(single) a. ri Is.Ce«ncrnrdi¢�eafing(Coanng sttppty) -
fndustrialiCommerola) nkcsidetuial Water Supply(shomd) i1T
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11rt ration
Nan lYnttr Supply Well: fa
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i�1�rCI pnrm)idamiScatinn No(PIN)
Sb.l,anmde and tortotude in degreedulinut"Iseconds or dedmal dcgrccs: -
(iiwelt freld,One MMeag ip sullideM) 0 ',12,.C enfi ran:
K.lt(arc)the well(s) PermaBeat or ©Temparaey
Sign eafOr'tifiodDJellCaenncror Dot:
7'''� I1v.t(ntmS ru> �nrm.I hrt rhvtxh/fy+lho7lltr nr11(a�a+as iirarrJ rxAtdrperrid rb ornitA2�tre
,.in this a repair m an axatdag wr]l: �XCs or IVo trvrR IS.l.vr•A4 02C.0100 or 15R jW'4C.01t.,.#"&Well CrmtrrvaWn S wahrefr marl that s
1,t'Ir,relsoryrolr.Jlllm,rlamwnwull.:onstn,utnni>Cfn,vnallonQ+r" rre�pfnintb,tunnnrn/d,u �IIAnfthftrrvymlAopbM�!/�MtvrinlM W�!llAlvtkr.
n natr nndrr t:l n:mnrf s xsrlan arm Ar aatknf fhrs•(orm, .•L Site n or addlilofml Weil tNdf gr
8-ForGen mbr/i1PT or Cttraed-I tm Genlhoriml Welk having the saute 1'011 rnaY use the brick of fiat pn�e to Provide 44tor f1Ni wen shedatafla or well
a)naltetction,anly I QW l is needed.. Wioato TOTAL NUMBER(if wclis ennsVttcllnn drtals. You may also attach eddltionaj Pawif ttoCessBty
ddllod:-____ tnwartrr ar tRSQ1Q7ICTim
`r.Total Volt AeptA bdow inuq iutillciv _ ._ ' � f E) �As1•Far_AU U g.. SubMn this fi)nn tvitlt[n 30 days of comptclfon of well
f nr mublplc K•ells l;ct nl;d.Mlu jfi(parrtnr(erampM-3thl tll(+and 2 rl f009 Conl911UCttort to(tic f wlD1ft:
10.8t01ie W Aft P tew;l bebtr top of taxing (tt) Divalaon of Water Rewturcoll ttdhrmatlat Proca"iap UI>y
((xarerruiv itr+Mtnecminp,tar"•'`
16171i1ail Sar*C Caatep,IRaldgb.XC 27d914617
lt.iloncholeaiametcr: 1� (in.) 24h.FQr la (jpR Wdie: in addtt[on'ta rAnd»tg ft fodn 10 the 04111001 In 24n
Above,also 5v9mil one copy of this fotm wilbin 30 deys of 0=1114mt of wdl
1Z Well cnnetrnenon metwa - — ee Wile ion to the fa(ltlwing:
i i C-.m,Kcr,mt:Ap.cnble,AirorR Fttttb otcJ i)Ivislon ofWater Rtttmrrcts.Undelground%je ction CDRuat Prugrom,
1Y19 WATER f+E'P17 Y R+1F.fI..L•S(1M1LY:
1636 Mall SWVioe Caner•,ltaiaigi.NC x 94-1G16
13s.Yirld(QpMl ��`� Me""of test: _— Etc,Irnr�Water�agRii&inieetlon VYdis: In addition to smMing An lbem to
the nddross(cs) abatre, also submit ortc copy of this form wHhln 30 days of
.1)63AIsinfi cKan type' Amami: tampttxion of well eansttnction to the jcatntY health depaAfient of the county
-- � - - aMere catitttacted.
Farm C.W-1 North C amfinn!)apnnment of lEnvirtinrtuxu d Q,ntlty-rAvistnnof Wamr Ro mmmq It r v W. 2 22-2o16