GW1-2022-09567_Well Construction - GW1_20221021

t.=r tat r an t t r
BIC=(GW-11 For use
1.WcR Coubuder Info n don:
T6 FROM I TO
,.
Well tbmtsltorName
ft c a m sgr In
&
NC weu CaattacW Certiti Um Nuader IL t
(4ro4 �6b"
C=Ww�...U it. n. m,
2.Wall Cmubsedon Pesadt 003 5 3a--),Gr .a t us
Llsdauappiloablriaellaweauedanprv&(Ia tnc.Cam:ftft varimra: fo ft, ZDo• IL L
3.wall Use(ckeck wen nse): a. m.
waa�Q*wen: i7
cuihiral unicipambl9c �FR MA L
33
(Hdcn8 Y) DRatMaatial wow
aPli'( ) R. ift t ht.
DRWdmdal water Sternly(elm e 1
N,yrWiesopp�+wens Z.20
tmtAsrRvnharan r lra..h,»itam#"D~wHuo:w �• •
14 . . .FACE. f --
Allttif4t Stop and Recevery DSalirttty Salami A
Aafadit Talc Ds tmwaw 1hai $
1 Teahmofogy j3S"dww Co=dml >w tL
(Closed Loaf) 13m w
C9eotit UW Rehun ftw u larder#21 ti eme b UD O rat%t +e rOGk �
4.Date walls)Com$ok d: '2 Z '1 Z well M# $
sa, "Cation: :•�
Faai rl0►vnerNamenn P Facing MoOfepplkeble) R ri r•' o
a `jv
Cauatr hand IdeaOmft No,"Q ►-.—
A,Lsdtttde and lon&m&ig eealminotat/seaands or ded"4mm.
(wwd field,an hmm is sudidmo) 2L Cmrdddltbu:
w
6.1's(aty&awews)dperma m or memmory Sip wkw of CAfted w
By stag dklrJ6r ,I hnby cp*dose dw wdl(s)wo OmW cowftcW is ante
7.b tilts a 'bD ala eststlng well: Yes orONO wlih IJANCAC A1C.0100 or Ild NCAC 03C dlM AWe71 Gbaa»n ft&wwm&and dw e
]Ydkk be re b,ANOWAte N 109CONSUNCdo d+ eatlop slid +t die maome edw ��+J'al+ +nrco�+d Iran tern prautded m rMwegowxar
- — n.&its diagram,or addidual well detellm
8.For Gwp vbeJDPT or Geotbm d Wre&having the came You may use the back of this page to pm b additional weak site details or wen
Sao,am(y 1 GW 1 is needed. lndieate TOTAL NUMB13j of wens conshuedon dom ls. You may also such additiwai pages ifusecumy.
&Mod-, wAvamuMmommm
0
F9.Total wen depth bdW land surfacer (�) 24a. For wti wag.; Subndt this t�'within 30 d of
br maltgrte wellalfet aII rkpfha rd�Fr�t(erm►�oJe-3®100'axd l(�100� coushuctiWitodwfoliowing: ; elian of well
10.Stalk water laud below top of coft:__ 2„(T (ft.) Alvm n of Water Resaatroei,Iotimnation Ptm mft Unit;
IrwriJsr law a above we6t&web61I Man movuhm remt,u..aubs ts_wr'Auum.16t9
11.Borebele diatsieter: UL Fs X ttl=�9n welts in addition m seadntg the form to the addmo in 749L
It Well motion met4od: a If' O.V above,also aulnnit an copy of this fiimt whhia 30 days of comylatim of welt
(l a q+',mmry,oaW dim p sk eta.) oottshnedon to the foliatelpg:
FOR WATER SUPPLY WRLLS ONLY: Dtvkl0n��' Rasottrees,U k rmad hQecdm Con&ol Frspam,
f �( 1636 Mail Sentes Cep,Rddg%NC 2769961436
13a.Yidd(gpm) /S Method of test~ 1 a`"' 24c, I WdIp, k addition m smdtng the tbtm to
.s�. r.,.,_- -• �n-1-in .---___-., 2 mil_ t.I_ the addttWco)'abme,also aobmit one copy dthis ibrm within 30 days of
- _ �— �__"_r.—M.� ..• _.� ....w��.+..0 w v Z,aavww.Y�:�.4IYSiFYs Vi HtO W�tt�
whom OO m to md.