GW1-2022-07116_Well Construction - GW1_20220729

F E�h 1619 Q6:43p Cleatwatet'W01f Drilling
Yl tGW X1 •For]ntcfnniUsc nIY*
WL -
1.Wtli C.on ,tor tnforin,L n:
i
�yit►.r1 �n p �
ie ft" V
1VC)1 f.n„tra�sta Nail,t _..-.
w ....w '41 it.. R.
' �, BR C tVc l
VC. Lit Cant"OurCe Ifkvlion Nmnber• —lir UM TO
tr, ft'
fb.pVNsit G ING OR lA ttlorwt MA
Coml,aryNnma /1(!q {'1�� � Tt1 —
C_JJ
x.iven Cnntitractlen Prervill tl: te.
nx a t/ Cntmty,SYala Yarinncc.,c7r.)
itlAamVoivrblu ralfranrrrnmlonlwrm t7.• A..•
3.lvdl irle(check wdl rite). e A is use u
Water Sn 11L
Pilo well: (1 ft.
Agricultural MtlniofPallPubNe in.
e 0den,inl Water Supply(single) tt.
C,eatICl7hii7(T9eating/C:oOling stipPly) _. R D7A A trc
(nAustrtailt Ommerelal esidential Water Supply(shArall & OUT L
t+ROM �
irH alien
34on V1 nter supply writ: p_ fr
;1moriltorblis f1.injection well: Q le -
Aquifer Groundwatcrttcrosdintinn -n 9 1rRL AC LAC TMCrt SAlini Battier
Aqui1.rStoraaeon4Re�'overy �, tY n- n.
Aquifer TcA E35tormwat"Draiitago d.
�SubMdcncc Control
Gxperimenta)T�ehlminpn+
C;cothetmal(L'iosed LOOP) �Ttacel IR
in Retuml Other(explain ulldar k21 Rcme ks) it. t► �i U(' _._
4
f1eOWennM Hcatin lg .� --
-�q—a� � f�.weil fd
a.iMts`u4st(aj e�,„npl�r,•d:.�,.._._.___...-_• >,<,n�ur �- .1. �n. � (
so.well 1.ne:atlon: 20Z O �L)l Q(if
r)
R 1
P sinnI Addroso,City,and;'.gip
[:,u,xy parcel N.,iiioatipn TIT--(PIN)
.rh.i.atitude and tonAlltude in degreesiminuteslsecondsor decimal drgrces: er ficxetinn:
(ii%Von fietdpnna lnMontl in'wipa eat)
15 y '� ----- pile
orckniralwe117_^antmator
6.h(arc)the rvelt(p) ermAnem nr ©17 t mftOrpry
///" 1 v.rlgrilnls fCA f fol I hprrhvrwrfJJ}}+Owt tort arlf(,j wa;Avarr)rY,Rg11fR7rd Ar 4ennntartce
IXCS OrM1n uytAl.SA.^i(.:AC'n�C..ylUOnrlSAtY(:AC.41C.'.I1Tf10Wai1Giietfrnrfin,.ylnnr►nrdRrr+rlrhrnrr
7.Ix this it repair to an exlydag well: cnpy n frlds runnel Aar wo pM'w to Its,wr.(!mvNar.
r'lhfs;s:,rcpett:,Jlllmrrknnwn,�clP�,onsln,e7Jnnir�itr�Ponm,Arrpininthn,rnnn,:nJ'rhu aim tBO$r7linoradditlott01wdldMlis:
r11,1mirFinder Alt ramarla wzam Orarrdiv ha0offhts,arm• ,BSc the:hick of this page to provide Addil"KI well site delnlls Or well
11011 may
A.for GeoprobeAMPT or(gaited-IlAnP GeotberenAl Wella having the saute c+ln ntaian tretails. Yau may also attach additional pages if naeeasary•
tx,»sin,ctitm,only I crw.l is needed. GtdicatOTOTALNUMBER(if,wr.11s
-----
�- , 3ulmtt[dtis form within all days of completion of well
9.wbtalt weli*Pm pelow land SPIN411:
f.nr mrdtlpfr%,rJte lit r ar;e.�nurr jAB'arrrnr(rmmp/a-3t�+.7lld'and if7ilfAff'1 eonsimtetilnt to the foi101v�R:
(ft.) Divixloa OrVYater Resi►iwees.I0%irmatlon Prue'MiM Un11,
lit.$taut wntrteuci befew tap of tailing: --- 1617 Man Service Center,Rater®1hNC276"-1160
1�'rnps fi7n:!fr,,hire cmtnR ate" '
24b,F r : 11)addition to Fending the form f OM AftiM in248
dl
ti.FOrNtotediametcro .--An) aheve,aJM Submit one COPY Of this f0 m vita 30 diiys eft cotaFletlCm of Wdl
it Well conttnietion tnethed! — aonstrt►ctiun to the fotrnwinr,
0 V.nuatr.,mmq•.cnbk,oirrm inch,etc.) DlvlllOn of W ater(Ittlln[rm%iUnderground titiftc on Coaltvl Program,
faOR VYA7 F.R SC PPLV WELLS ONLY:
rw Mail Soviet Cennu•,RAteigb,NC 27094636
2bc.i,Qr�• c ,•"t•&1(nfOetioR Wetly: in addition to sanding ih To
form
13A.Yield IRpat) MctMtd of test:—Lot the addrOSS(cs) Above, alsO submit Ong Oopy of this font witftin 30 days of
,Amount: - pmplution of weil consuuClion iio the county health department of the county
13b.1)Isinfectlan type- wvwre connrrected.
-- l
Vmill Gw-1 Nardi Cl,rnlfnn i�apnrfmont of iinvlmnmroral t.)nallty-Division newWR rtmJtntrcav Ren+raeA���IQl fi

I'
I
'lillon Dl I*r SWf.4mwt CwOffaMon
PJ
l hereby catWy that:the ObM reft.a ced vveu ww in aPpearance la a= dwm with
all COMB-well rnlm
Well Dd11er�
Cftrame Aar�roubpd� �' ICI" 2�—.�—.
Totd Doh;.. �t p'�. - -- --------
Drive
i
i
I