GW1-2022-09669_Well Construction - GW1_20221027

828-622 724i p.1
Feb 151905:43p Cleatwettel-WellDrilling
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,x nsm+ctinn,anlw I CrW-1 Is needed. Intlicata T4'fA1.;vUMBER nr�•rils con9trltettnn detaft. You nlaYalso altach addltinnai pages iFnat essat}?
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9.TU21 well rleptt&below rand xurlaec: y �(lt.1 :ton• If.'or A� H^___WAlts: 8uhmit 011a fomn within 30 Joys of completion of%tell
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III.3totie Water level below top of easing: (ft.) Aiv;s!DA of Water Resaura:es%Information Processing Unit,
1('Mahp!u%%I1.r r+lvtva cAsing,trsc"•' 1617 B'lnil Swv:ce Center,lt4leigh,NC?7 -ib 11
Borehole diameter. fin•) ?.ah.Fur 1alCetinn•w¢ll1i+ 10 addition to Sending the Parris 14 KIM tld010M in 24n
Alrove,also submit one copy of this form within 30 days of compledon of wen
12.Weu cansirncllnn method: sonstruadon to the fallowing:
(i a,mega,(nrtrp.Come.dit'oc.'t mall,cic.)
Division ofV4nmr Resources.Underground injection C.oll"I Program,
MR WATER Sr_APJ V LLS ONLY: Ir,36 Mail Service Center,iRAMS%,TyC 7,709-106
1314.Yictd(g Methntl of te4L• +tom Ilnr yl'atrr 4nn<z1> &ipieeflon NVdis: In addition to sanding The item to
the; oddra cc(es) nbove, also submit one copy of this form williin 36 days Af
tab.Disinfection type-. .Amount,- completion of well construction m the county health dMantne:nl of the county
vilare constructed.
l�nrnt C;IM.I Nncdc[.arc+ticmAcpnnmcnt ni t;iwicrinmcnrai Qunitty-Aiviscnn ot'UVaccr Rosottrcee Rea+roeA2 22-7.ai 6

Date: 4�
Well Case: Well#; ZDZZ- DDUy
Zp Za
Name:
Address: tax De kh', LW&L I& WG
Pump has been installed, well head ready for inspection.
Sign: —�--
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