GW1-2022-03432_Well Construction - GW1_20220318

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3.Wen U3e(cheeicwen use): 7 S S 7/y m T1, "L .
Winer Sutpply WeII: $ A� . 1°' 7''�'
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D S.or •71lsi7RiAL
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D iaVCammercial R' �ppIy(single) g &
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NIoa-Witrs �" DWells>1 000 GPD
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? ( 22.Certification: e
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G Is(are)the weII(s): permanent' nr DTempor>arY O . � sigaaans ofCacfiadDift
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this a repair T4 an esisting w&-- �ayes or o15A' AC' ' 17i4C 'Q4 y rT,e (s1+'� I ab+ernr�edntaocwsiaJme
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8.For GeopzoyrJDpT or Closed-Loop Geothermal WeIIs _ 23.
You Srte�or additional wen details-
do o[6 CY 1 GW-1 is-needed.3adicdte TOTAL ER ofwelis a (�d'Sa ee hiRcu aft Box}You
P��P�de additional adl oa�ux�intio
may also abehadditiood pg.
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24.SOBMITPAL Il�ISIRUCTIONS
9.Total well depth below Ind sarfsce: 3 Z(J r
ForraJJlpls�r�rlEttcQdeprl+o ff��R( 3��,�1�� () submit
this GW-I withia30 days ofweIl eo letioa
_ mp perthefallowhug:
10-Still water level below top of ewim, �p f) 24a. For All WeIIx '
jjvnr�leadtr�He ;+- (�)- MPtncessmSU 1 C Division of Water P—Amces (DWR).
Raleigh,NC27699-1617
11 BoreboIe diameter: G i�7r (m,) 24b.Foi Injection WeUx Copy to DWX UnBeWo uod injedm Catm,(NC)
IZ.Well coasfrection method:_I 1 r�'�a�a, ^ Pmgram.1636 MSC,Rafe*NC 27699-1636 .• .
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FOR WATERSUPPLY WF.T,iS ONLY: Z4d.For WatWer�WW�eGlltal�WroWde '
Un.Yidd 0 Pmga7a,1 lI MS Dyer 1 W.D
(EPm1 Method of test: Peimst C,lZalei C 1 11 'OGPCFJA
13b.Disinfiecdon type: '1 Amounts- 12-,
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Pzvixd6.6-2018

E-69SE
Web-FM Streamlined Sales and Use TaxAgreement
' 12-M
Certificate of Exemption
This is a multi Mate form.Not all states allow all exemptions fisted on this form_Purchasers are responsible foi-knowing if they
qualify to claim exemption from tax in the state thatwoutd otherwise be due tax on this sake,The seller may be required to provide
this exemption oertifioate(or data eiements required on the form)to a state#4 woWd otherwise be due tax on this sate.
The purchaserwill be held'liable for any tax and interest,and possibly civil and criminal penalties imposed by the member state,
if the purchaser is not eligible to claim this exemption.A seller may not accept a certificate of exemption for an entity-based exefnption on a sale made at a location operated by the crierwithin the designated',state if the state does not allow such ah
entity-based exemption.
1 ❑ Check if you are attaching the Multistate Supplemental form,
` ® If not,enter the two-letter postal abbreviation for the state underwhose haws you are dawning exemption.
2 ❑ Checc ifthis certificate is fora single purchase and enberthe related invoicelpurchase order# -
3 Please print .01
Nwm of purchaser
f7r
t�
CRY
Business address
ZP Code
r'u►cheser's tax ID number 1
`7072 1%2ft of issue counhyePissue . .
If no tax ID number, FEIN
Drivers feense number/Slateissuid ID number F oreign diplorrrtd number enter one of the folovdng I steG9� number
` Name or seuer from whom y I are pure�eyn8. or
rev ff n Brothers krxr
1676R Hwv 26R W
-,amrs aar aess Elkin,NC 28811 mate code
4 Type of business. Check the number that describes your business. '
Ef 01 Accommodation and food services r [:III Transportation and warehousing
❑ 02 Agricultural,forestry,fishing,and hunting ❑ 12 Utilities
❑ 03 Construction ❑ 13 Wholesale trade
❑ 04 Finance and insurance ❑ 14 Business services r ,
❑ 05 Information,publishing,and communications ❑ 15 Prolbssional services
❑ 06 Manufacturing ❑ 16 Education and health-care services
❑ 07' Mining
• ❑ 08 Real estate' ❑ 17 Noaprofitoilganization
❑ 1
09 Rental and teasing ❑ ov
❑ 10 Retail trade El 19 Not a a business
t
usin
❑20 Other(exphain)
5 Reason for exemption.Check the letter that identifies the reason forthe exemption. ,
❑ A Federal government(deparbnent) ❑ H Agricultural production#
❑ B State InWovernment(name) ❑ I Industrial production/manufacturing#
❑ C Tribal government(name)_ ❑ J Dbvd pay permit#
❑ D Foreign diplomat# ❑ K Direct mail
❑ L Other(explain)
❑ G. Resale# .•
6 Sign here. I dedare that the information on this certi!icate is correct and aompbte to the best of my lvioWedge and belief.
Si of aurharaed WMWWRini name lice Tdk Date
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