GW1-2022-07012_Well Construction - GW1_20220725

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8.f�r Gmnrobe/11PT ar G9nwet�l�g1P c,m"rAia»driails. Yflu may also awhadditiontil peV if iummatl'
mnsneratian,only 1 GW.t is needed, kndimW TOTALNUMBER af+vclls
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MMEMLIMMOBW I.7r.►►1t+veil dcptll i►e[mv land speli►cm 21t.for8t(Wills: Suhttlti thiv farm within 30 days of eampletion of relf
frnrrunldplewrr).etitlnlidtri�ltefd eruct{crp+nj>A,-3�+Jafa afdi(1i}1at17 collaiructionloihef 310141ng:
Ill.3tPGe tYGMMIc}+kl ftet6w to Of CaltiP$- (fr) Divifilon crWOter PAS01wets,luffirm'001%Frove"ing Unit,
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11L f omholediameter- (in.)� ��,,c��r�annann WQOre to addition to F"ding this f(q f the nd lcm in 24a
ahovt:,else,Submit anc copy of this form within 30 dty&of complutltm Of pied 112.%Vnli cunrtniction method: r cntutraadon ro the fatlrnvru9:
(i a,m,yr,rotas•.r*10.plr%t(me16 etc,}
_ Dluilion nfVYatel'6teiwt'ees+Uadergtrounrl 119eet160 Coatrnl roSrom.
PM WATF:tt SLTPI-V rWELES ONLY-. 7 GM Mau S4r vica CaPAW,RA1610,NC 27094636
U M�Ilttto Of 1e31: - :'--°•rat 1r S�,ne1n &inioetion yyt t� In addition to sanding rht fa m to
132.Yieid10pmJ the addrass(cs) obovo,also submit ane Copy Of this fOlm williln 30 d1W of
lab,Disinfection Amount. c mptetion of,,veil consaruc0an�the eolmly health doh dMent of the aunty
cFf?a- whQsa amatmeted.
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