GW1-2022-03444_Well Construction - GW1_20220311

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rrprrir antler n 21 remarks.jtrrrrn ornnUm hark of rib faro,.
23.Site diagram or additfunid wtill detnlis:
R.Ilir GMprobe/DP'('or Ctnsed-1 atop,Geaattrrmat Weirs hnvfng the same You may use:the baste of this page to provide addhicnitl well silo details t,r teen
,xnstn,ctinn,(ml+:I CTW4 is needed. rridicate TOTAL NUMBER or'wrlis cgnstn'dinn drtaits. Yore may also attach additional pages if neceoftry.
driltul:�.„.
S S•,OMMAL JtMi' U(.TIM
`�•Total well depth belowland surface: ,(te.► 2,1st, Irgr AH- Welb, Submit this form within 30 days of completion of well
t"rrr andriple relic liU Mi derrlfi��rTrJfcrrar(exaarnle-3(a�1!!R'and l lntaq
cmnsittictinn to the following:
in.!naive water v rt- lbetop,top of raging- _ (ft.) Division or Water 11cmur'ees,Inft)r•matlgn Prore ing Unit,
- {/'rcarrriurrd lc.rlrrrae7ltynjt 1rar."•" fblT 8ltait&rvlce CeaMr,Reltdglir)VCx1 t(99-tfit7
l I.llorehAirdintnetcr. in.) 24h.Rnr 1191ertiall W llS., 4t addition to rending the form to the addrem in 24a
t2.Well constntetlnn method. �� abavc,also submit fmc cagy of this form lvilhin 30 days of completion of well
C.m(i ,t;�,mttr3.G,tsk,direr!pttsi,.ctc.i ---- constmetinn to the following
FOR WATER SCPPt 1[WE►LS DNI.Y: Division of Water Rtsaurcr%Underground Tglet'tion Control Program.
I631i Mail Serviet Cente,Ralato,NC 274WI636
13a.1'irtd(gpel) ID tTethotlof test: Z•iC; Ur Wafer Smonly&Inieafta W-ft in addition to sanding the fbrin to
r.iA.Disinfection the nddiess(es) above, also submit'one copy of this fool within 3Q days of
'Ne• Ar-— nntmt.. c,tnptetion Of%vdi c[instmcfion to The connty her4lh[kpalfinent of the cnunty
where cortsttncted. j
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