GW1-2021-07435_Well Construction - GW1_20210921

WELL CONSTRUCTION RECORD(GW-1) For tntmal Ux Only:
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a.Date Wdks)Completed: Q t 5 a0 kl wen m# 3 5L ,; I n ee V0 a
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5b.latitude and longitude ba degeecalmiealun/aernnds or dedmal degrees: n- c sing U ll It
Ctfwaiseta.ase Wong iemeseient) 22.CarfiHation: Ire err,, p�JR
30 si.� x
&W,am)tkewew9)&wmammt or [yTeeeporarp si eof w Due
By tl8s finea I hereby aotl(y thee the wad( was(swS)aotradsand at aaeavdmtae
7.Is this a repair b an*Xbaft wen: 0Yes or ON- vM 13A JW-W M.0100 or l-U 1VCAC WC AM Wed Cbms&xc m Slrmxfm*and that a
Ifthia fa a rspelr,fiff ors b mm wed as orm mn b#onsatma and e*&m the native qfdm C10PY aldrta,V= has"mprovdedloo the well owner.
repow srder#21 remo sft*as,w m Av bm*vf0 tefonn. 2&Site dbgram or additional wdl desalt=
L For Geoprohe/DP]r or Closed-Loop Geothermal Wells having the same You may use the back of this pare to ptovide,additional weft site details or well
mosbuctioM
only 1(FW-1 is needed. hodicame TOTAL NUMBER ofwegs cousbuction.details. You may also attach additional pages ifneoessacy.
4
SIIIIiYIITTAL Il1511tUC1IOluES!
9.Total WA depth belowland smfaea 1/� (a) 21a.For AN Wars: Submit this Fam within 30 days of comoetion of well
F-mublpiewWkfttaAdgWwjr (mmsple- oonstiuctionto the fglowbW
10.Sta6c water loud below top of eadng: yZ ( ) Dlvbdm of Water Resodnrees,hdbrmadon proemtttg Unit,
llwaw bwd gobom earft we 1617 Ma$Service Center,RmWgk,NC 27699-1617
1L Borehde dbmeter: (h am) 206 For Iniectim wenx In addition to sending the farm to the addnss-in 24a
iz WeD Condrndion taefhe� 14 t SOT v9 2 abom also submit are copy of Bois'form within 30 days of Completion of well
(i-e-�f9.o fie.&ac P-k Cie.) Un the II
I
Divisim of Water Re oureer,iUnde gioand h&ctlm Control Program,
FOR WATER SUPPLY WELLS ONLY (� 14336 MaR Service Center,Raleigh,NC 27SPI-1636
13s.Yidd(Spm) I Method of teat: L 14a For water Sato do bdeeffm wed in addition to smdmg the form to
the addiess(es) above, also submit ne o C opy of this font within 30 days of
13L Di an type: . [ Amami completion of wdt construction to the county heath depaAment of the county
where Consbacted.
Facm GW-1 rmsth Cmotma Dqw aeot ofFnwmmm r dt Qoday-Dmn m afwM=Rcwmcm Revised 2-22.2016
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