HomeMy WebLinkAboutGW1-2022-01001_Well Construction - GW1_20220107 828-622-72:41 P.1
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4_ilatcUVetl(a)Completed: ,��;,[.�l.Well IDl/._.-r---._--_.�...�. �.1L J �• .. __..Y_.....
Su.Well i.nralian:
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�X .•.vimini"Ohs'";,rim J hrrrl!ptvnrify rhm life am.11f)avit aam:J mpup trlpvf at drrntAlLm.r
%•to till.a repair to ant:xtvting well: 1lrs nr No x:qh l.tt v'C`,tr.'o2f..!/1tNl fir 1.fA NCAC d1C.'.B?00 R'e1l nnttn,ainu SlnadaOt and that,:
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R.l%fir CrnnrobefllPT or C.titaed-l.,onp 6QWhermm Well%bavimt the same 1'nl,n1ay uw+file hack of lhis page to',prnvide addidonill Weil Aite delnik or well
,>t,nvinn:tinn.onl�1 CsW-t is needetl, ilKfiRntc CQ'fAl.NtJMB1 R nf+ariLc con9tnirtinn defails. YOn may 11190 attach t}dtift1aT181 ItAQCR IfflttCEbPflty,
`'•T41AI waitdeptk Imlow land surfit.cc, T5-----_--_-_--M) ;104. f er AM WtiA: Vibmit tills fb m witiiin 30 dBys of compictian of it-ell
f•�rmajlnptc ,OfclivMidrtin1follcrenteamnjph dn7rlt?'nwIl@loW) 1'1111atf11C1in11tothe following;
l p,SlAtic watmievtl t low..tap of tn,iing: _. _ (ft.) I)ivIsinn elf Water RemureeA,iRfnrmation Prtxeemg Unil,
11'evttrr 6ncllritivton vpring•toe�''•/^�t 1617 Mmq Smkc Center,RAtdgh.NCj76"-Ifi17
11.Ilarchale dlpmrtcr:_-_ Ve In.
---( } ;t•lA"Tar IwMerlow we la: to addition to sanding the fottt►io dtc tiddfesiti in 24n
xl+nve,also wfunh onto copy of this form within 30 days of eomplegolr of wolf
I?.1Vrti cnnatnlctinn Method- -- ---- -�_ cammictinn m the follorAni
0 c.Rage:••romf)••r,�1.{e di,'eetinu11,c1e•)
►`M w.�rrti�i,Prr v wFt r otvl.w: ---- -----' -- Division of Water Rtaotlrcea,Undergrownd 011joction•Contm)hgrnm,
7 rim tYtan,4ervf m Ccntcr;statelgh,NC 274'106.11636
1.s-Yield(gDai) ��_ _Imetbad of test:( 2-le, Rnr H`pf T Suep1►-&(R12SMAR We 19: In uddRlon to Sontling the ibtnt in
div riddress(es) nhnvo.. 0I50 submit one Copy a till$ fban wiQlin 30 days of
t 1h,lrfslnn:Ction type. AmnRnt:, r,.npletion of,yell emmacdon to file'courtly"in dtpanmrM of tnc munty
whore cortatmeted.
t'W,t NoaJ,t;nmtinn117epnnmcni.of t:u�knnmrr;tnl t;ls;tnty^Qivicu,n nP Water Rastairms
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