GW1-2022-09071_Well Construction - GW1_20220923

Jan. 24. 2018 10:58AM Env. Health No. 6111 F: 1
' k
WELL CONSTRUCTION RECORD M U-1 Fq hftmal use Only
E
1.W i Coptracto Iuformaao � •
Wdt CantrmortJame TO H
0• �Or'19 YO
td n
NC ell coma CattBaBoo Nvanber i!w.Wvr� 0e, ct�A &,wd Se �e,W mom01111 -
110
76 a V
MUM
7-Well Cult'rutslen permits:
UstnUo icable,renemuardonpem uPA EUC Cmmq,km Ywima,ay' tt: tti bL
3,Well Use(eheekwell use): n. tr. j In.
[Aq,ji*r$tqrW-dR—vc,y
Sapptyfvepegittua0amai(�P�fmB SUPP►y) ��s1tc idta Wwater supply(stw tr �hiavcpmmcreiol [')Roside=lWaterSupply(shottx�lion esterS •caringLon eFaRecharge []GtaupdwetarRemMietion
fer$tgrW-dR—vcry 1}SalinityRallier 1r>'A "6o-eTROM
f rTcst -0stotmwelerDrainageiment13suhsidencecon d L R.
temmt(Ctmed Lapp). DTaeer iddruomtesmat(ffmtiridcai igRam- Other uaders2tRemarks "W1°`t`
rt -
d.Date Well(s)Completed: 'f '2 well wx 1L 70
Sa.Well Locations 7� [t .7y't R• Giea.�i Z
�c�lr GBH L "
Fsa'IilylOwneritaaae FeeHilrtDE(ifcaptitobb) � n' .-
per- Addemt,City.wd Zip ft.
. j
Conaty ltaeoeltdemi6t�fionNp(P1N)
...: f-k,:.,..a:�•:�:�Uri;
sb.Latitude and IougDode in degrualminutealtuxonda or dedtnal degrees:
retwall AsW,one is e� C, �O�d 21 Certification;
6.TA(are)the w"Apermtmtnt or QTemporary St �t to ffl art�a Wdt co Mar t?ao
By etAffhng rhtr)6rft Ihere6y Carty rha the watt(;)even{fang)Mmin etrd fi amikdaaCe
7.B tilts a repair to so a kdog well: QYas or D14 w&A ISAIVC tC 02C.01oo or lJA AVC 02C.0200 Batt ComntamnSm*?*aadfiot o
{(r1+kUorspal,)Ittarrinowtvdrtaw,umnulnJoaar6aoaua'apla701&nMmVde copy althis#vmdAnbaoprovrdtdto die 1rWower.
r p rrater821rr whsaffenoroodu bad q/►blsform.
23.Site diagram oradditiontit well details:
L For GeoprobtMPT or Closed-Loop Ckatherniai Wells having the saute You may uses the back of this page to provide additional well site details or well
owsbut:tioa,dolt'1 OW-1 is needed Memo TOTAL NUMM of vmh constnictioadetaffs.You may also attach additional pages if nwwary.
- ddUed: S[I8Mt1TALiNS7'Rit[`TT� .
9.Total well depth below land Cartago I? �j QL) Us.For All wells: Submit!this from within 30
days of completion of well
HarmdaplexcrtrlvrarJ4e7t.(/dill ( eijVM'MdR@t eottsnttpdonto the fdowing
L Staae water lad
rum topoftesing: -—(R) DkidoitofWaterResourm,InfornatlonPmcWugUnit,
srarer teeel trabone I617 Mail Se mY a Center,Raldgk NC 2789-1617
li•Borehole diameter. (in.) 24L For tnl�on ti{retla; fn W4ion to seadmg the from to the ad&m in 24e
12.Well construction Method. 't&I^!(h ate,also submit one essay of this f3mn wititht 30 days of completion of Well
fk man roluy.cable,&-A punk eta) cotutruction to the foDawing j
FOR WATER SUPPLY WELLS Q1YI.Y: Divislon of Water Rcsoorea,Undergroand Injeeaon Charm!Program.
1636 Marl Service Centel,Raleigh,NC 276991636
13L Yield MM) l Method of test . 24c.Far Water Sunpty&Initetlon WeOa: To addition to sending the from to
!� the address(es)ahpvo,at%submit one copy of this tam within 30 days of
tab Disinfeedon type: l r Atnonor. _�yt s comptetimt of wall construction to tho county health department of the county
vAnaeeonshuded.
FotmGW-1 NoRaCmntiasDe�artmeat afFsoimameanlQmiiry-DivisianoFWauReror Revirod2-22 2016'
i