GW1-2022-00123_Well Construction - GW1_20221219

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WELL CONSMUCTION RECORD
Forlmemal Use ONLY:
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1..Wen Contractor InIhsmation:
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5L Latitude and Imugaude in degreesiminmtedsavads—deChunI degrees: 22.1 Now �✓t�. r
(tfwell5eld,awk4flougissuffident) J I `
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� Si�ahue ofCertifred WeD Conhactat Date
6 Is{are)the we11(sx`L1 erumnmt or OTemporary _ - _ - gy rhtsjomt f&,ihy eertijy dra the,vdl(s)Mae(vex)amnaaaed in acwr dmwe
' tvtih ISitNCAC 02C 0100 ar fSA NG1C 02C A200 Weff CammucdonStm 4W&mid elm a
7.IsthisarepairtDaDexistingwen: ❑Yes or C31�To avpyoftlrir,randfasbemptovldadrotYmvdlotmer
ljrhis is o repolr,jd!oar 6vasat vrJ/oavaaraettarr tnjarmarron and erglanr the r»mx ojthe
repadrrmder:21 xmmfasectranoran thebat�ojthlsjomc 23.Site d'mgram or additional well details=
You may use the back of this page to pmvide additional well site details or well
&Nnmber ofwAs eoastractak construction detals_You may alto attach additional pages ifuooesmy_
FormaWomir, lonornon-iearersrVpdyuwJhONLYvuhrhe—caasavrdogyoucan i
sabmil ortejomr. SUBMITTAL RVSTUCITONS i
9 Total well depth below land mr&A= (tt) 24a.For AD Wells` Submit this fob within 30 days of completion of well
ForaudtlplewelL Raalfdpthr{rdff-c t(--ple 3@20•md2(a1fo0') constnrdiontothefollowiaF I{
10.Static water level below top efe�ing: (it) Division of Water Resonrces! ,;Ioformation Processing Unity
�maferlevrl isabomcambg tore-fa 1617 Marl Service Cemter,RaletkNC27699-I617
IL Borehole diameter. �if
(in.) M.For Iniea&on Wigs ONLY: In laddition to sanding the Am to the address in
24aabove,also submit a copy of this'form within 30 days of completion of well
12.Well construction method: construction to the following:
(ia auger,rwazy,able;diioctpmb,eta) Division of Watu Ptesonrces,Undeigmmnd injection Confiol Program,
FOR WATER SUPPLY WELTS ONLY- 1636 Mad Srrvice Center,3W gb NC 27694-1636
(8Pm) U Zoe.For Water ft&&Injection Wells
13a'Yield Mettrod of tech Also submit one copy of this,form within 30 days of completion of
13b.D'ldnfecraon type t/�Xl� " Amour weft conmuctioa to the cmmty healthy department of the counly where
construchA
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