GW1-2022-09740_Well Construction - GW1_20221027

F(m)15 19 05'.43p Clealwatermin-r-at,u
W—E —L!QO�TS'�RTJCTION RECORD(GW-•11 i�nr lntemnl Use nay;
1. ill C.antrartor Information: n�� �.--- --------- -
A ? J m N TTO
ZONES nsscw
Well Canvanlor Name
SIC.WMI Canrmaos Cartincation Nasnl!cr � 1, �y Me NN QarT ORId�1FJt 0
TO PIA 6R Tpt B83 TErigW
t.natpnnyNamr. r 16.Wi'FBRC NCQRTI►81N that I -tao 4
N TO CfAMET13l TA S
2-Wef1 Con"rnetinn Permtt#: ft. tn'
idst all nrpiieft've atfcattclnimlanpatmltr(I.r.11lC CauNyStM�t/,rrlanercr��
n•• � 8uw
3.Well iric(cheett wC11 use): 17 a N
WatersupplyWell: FROM o n� a •ttttr. rsse ttnaL
hgricuitural MupicipaUPubFic o t`"
toetxhernnai(Henting/ContingSUP111Y) ItmidentiniWaterSupplr(cingla) n,
rndustrialMommercial ResidentialY/aterSnpplu(sharetl) a f1)JZ - MA L GMT" MrM paA outr
Try
lrri onion n. r�r ft,
t,ron�t nl;r 5npply V►rll: to. e�V fr,
Monitoring ©RCaovery
1ni""" a Well: f4 R
Aquiferltcebsrge QGroundwnterltalnediat[ntl 70.SANifiGRAYSLPAC Fo ,
AgtiiferStoragp rind Rccovct}• a,4alinity Snaicr NRof[ ItiG >f�Trt�CG�18 MCrttVn
SmnmvmterDrainage ft- ft,
Aquifer Tr-q tt.
Experimental Teelmalogy Sutrsidcncc Control
C=thrrmal(('losedLopp) OTrat:rx 1Rft.1, Tb� Iryarl.t ri{ra{nrnsgeee,l
Cfcothrxanat QLcatingppLing Return)um} t7dler cat tarp 'n utt4cr ii21 Rcmnrka) l Jr.
t,Aatatit'e[I(s)Cnmplctel - ?Wcll lDttJ ft. it. r�
�,
Su.Well l,neafin Ct, `Q it. 46
Faci1itNeOvnerllamc Fa' [Do(rf�Plicnbta) ..
Physirrl Address,City,and Zip Iu gl MMAR1f
cut„ny Natal rdentillention No.RIM
it
�U.1,atttudr.andlnnRltudcradcgtroeslmtmucslsecnndsordccimnldcgrcca: -- I��;"•"' 'r'' `�9
(ii.wllfialtt�nnaini�engiRsnfiiclDON `C� r 7 .erfitil�trinu; �n�Q%`3�'
IV
C Is(arc)the well(s) Permnn 'ent ar OTemronr Si�naturc afCQtrfied We11 Conttaetar °
TTT rP atpninl;rins jornr,!lu'rrhv arrlrlfl+that the lo-JIM war&-}antrsrturfid in acanrdmrcr
11a lb a repair•to as eMsfingwell: lYcs or�No n'drlr lSt 1 t',tfi n2C.4I0D m'tSA,YCAC JlTC'r i12110 We 1l Canstn!arinn Unmlarda rm,l thorn
r rmalinn mulrr lain Me uamrc of+ha ••anit nfthrc rrrnrtl haA7+/.M f/MPldlhf fi Jilt!Wd t Moms:
J,,dA.ix:>rrpafr.fillnutbiawn�Wll.nnunrclrrurlgtn P
t::Palr under A 2t ramarkrsmimn oronihr hack 901 jinn. ;1;,Site tiiagnm or Addltiungl Walt dafuitst
R.It11r Gen roheRlPT or GrtseA-1 on Geothet mil Wclishavingthe sarpe you rp1O"lsr lltc buck of this page to provide addit[Om11 welt silo tktnils to ,vrit
txnrlmetion,only I M.1 is needed. ndiaate TQ'rAi.NUMBER of%vellc constntrjion tletaits. You ttwy also attach addlt[onat pages If McssarY
drilled:,,,•• it nnra+rrrA r-1ir+si Rill;lTOlV9
n,TOW..a depth below lnnd sumac= —V* 24a. - .aH W-dh-' Submit tLis corm wifltin-10 darts of compir-tion of Well
Nnrmulttplc wells avP11di;mw,;rrr nrant fnsamnh,3@07(ra4412 lnnj t;arigmmlinnMINf0llOITM9:
In.Static Rater level below top orcasinge (ff.) Division ofwater Resourres,iaihrmation Proeessing Unll,
P'nrer lame!is Oars cming,rtar 1� f 1617117ta8 Slarvice Center,Rstelgb.NC 1700-1611
1i.1}ttr,ehotcdinmetcr: 9 1 tn/.�}1 24b.For laicVjon We .. In addition IQ Iiettding the forts 14 utq raddraw in 24n
12�Vcit el►nllnlellnn inelhod' �W'`'r ai)ove.nWn submit one copy of This from within 311 days of compi Wtm or Well
snnsttuetion to the followinr,
6 e,Auger,mmry.cable,4ircct posit,etc.)
Division ofWaterReenurrev,Undcrgronnd Ttlj�on Conn]Program,
F*A WATER SUPPLY WELLS ONLY; � 1 f!36 MAii Servlec Center,RAlrlgh,TIC 7.709-1636
1.3R.Yield(gpm) Metholl ar teal: ►'{ 34c trnr Wan.r Cnndv&iaieeflan Weller In addidou to sanding the ibrm to
Ilia address(es) above, Also subunit one ropy of this fomt within 30 dttye OF
fah.Disinfection type: _ Amormt^_ completion of%vctl consnmction w tho county hw ilth departmenl of the county
whrare conatmrlod.
Pam)GW.I Naern,CamlianDapanment of t;n-'oanmentil Quality-Muismnof waver Ran—
Revisdl2 22 2nt 6

i
well Driller self-smut Cermcaftn
i
Owner c1� _ _�.i-�� Neon+well:
grouted m appearance hi adcmrdanae with
I hereby�fihat the abc�ce x+efex+ertced wdl,way
all County Wdl gales.
Rex_ ���`�� S` ned•
2
weR D&Ier: ' -7-
"Groubed-
Construdiorr C�anxt:
Total Ae*h-
g'
Casing
Diameter:
weightf Thi& -
Hegt�t
Drive Shoe: