GW1-2021-00413_Well Construction - GW1_20211206

WELL CONSTRIICTION RECORD(GW-1) For hmmei Use Ow,
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2L We diagram or additional wen des.ns:
L For Ceop+ab&Wr ar C7aae"aW Goodwri it Walla bwlog rho am YOU my me
details.the
back of
Yoe this W6e to provide additional well site details or well
oeastrudtaa,only I OW-1 is aeoded..Iadieat TOTAL�ofwe�. may eleo all A additional pages if necaawy.
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9 TOW veil de�tb blew land aarllaee: (B.) 24a.For AM wa0a: Submit thin 1n®within 30 days of completion of well .
Fo►aod Je edk artaQdt�la lJd�bisrt(ma,rpte-38100'oad2®l00� eanehaetim to the following:
16.Static won loud below 4p of eaahrg: �lfwaar k►e!k aA, c=k&are (fl,) Division of 9Vater-+- D sion 1617 Matt ServiceCanEer,Raleigh,NC p Us%2 C 76994617
IL Boreiale dinaeEer: ) 24L For LlaatlM Eft In addition to sending the farm to the addtesa in 24a
12 Well eemh7,e i a ase0ed; �t��r- ate.also sulbIDit me oopY of this form within 30 days of completion of wen
(+I��7 Able dronerruk dl) construction to the.Sollowing
FOR WATER SUPPLY ONLY: DhMou of Water Resources,l7ndwV+omd Injection Centrol Progreso,
11 .106 Mall Servlee Center,Raleigh,NC 2709-1636
13a.Yidd(g w) Z Melted of u sk 24e.For Water Sanely do Llectloa Wens: In addition to sending the form to
13L DWafeWaa Ametrak ,.1- 'the addtaes(m) above, alsb aubmit one copy of this form within 30 days of
10 oompladan of well eomhuearon to the camty health department of&a county
where constructed.
Form GW-1
Ntarib 4roliaa Dapaelmaot ofl;ovieoomsnW f2eality-1)ividaa of Water Rarromges !r Revised 2 22-2016
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