GW1-2022-07016_Well Construction - GW1_20220725

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6J5(are0h6*eN(S)` erW=ear or Z3Temporaty SigoanueofCeitified Well Comraemr
Sy.signhrg ilitsfaim,!hereby certify tharthe i%Vl(s)was(were)constructed in accordance
7 Fs tflis:a repair fo an esis[ing well 'IYes or �3Vo tvlth-15A NCAC 01C:0100 or I5 4 NCAC 026.0200 Well-.ConstructionStandards and that a
ljUlu,'ra repau fJl out litmsm lvvll cousbuction informatiai�Gird eap(ain the nature ofthe copy ofthis record has been provided to the rie!(owaer.
repalrrmder#Zl remdr/asecfianaron01ebacicaff/rirJvrm.
23.Site diagram or additionalwell details- 11_
8.For Geoprobe/DPTnr Closed-Loop Geothermal Wells,having the same
You may use the back of this.page to provide additional well site details or well d
t oDsfiuct on,only 1 Cr W-I:is needed Lldieate TOTAL-NUMBER of wells constmctiondetails.You may also attachaddltiaualpages if aecessaty.
drilled:. SUBRUML INSTRUCTIONS l
9 Total well depth below land surface; 32.5 - (ft-) 24a,For All Wells: Submit Ibis form.VAthni'30 days of completion of well
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Ili.Stafic-wate levabelow top of-sing. �r� (ft•) Division of Water:Resourees,information processing-Unit,
r,tuft-level&abaPeccsirrg.1cre'+ 1617' 'h7ail Service Center,Rateigh;NC 27699-1617
12.B'oreholeAi inleter. 011.) 246.For Infection Wells: In addition to sending the form to the address in 24a
above,also,Submit one copy of this f&M within 30 days.of completion of well
n W&COnstrDCtlon method: e�1�`� construction to the following:
Cie.auger,
mtary,catiTe dimctpastr,etc
Division of Water Resources;Underground Injection Control Program,
FOR WATER 8[IPTLY WELLS ONLY: 1536'NIail Service CCnter,A216gh,NC 27699-163fi
,13a,Reid(gpmj Method of test: 24r.For Water Supplv-&Wj&tion tiVeU.S. In addiition_W sending the form W
the address(ec) above,also submit one copy of this foiin within 30 days of
13k Disinfeclian type lY Amount: completion of well construction to tale county health deparituent of the county
where:constructed.
FomGW-1 NorthCarolina DepartrawofEnvimnt ullQuality=Division ofWaterResounes ReVisCd.Z-2 g01(