GW1-2023-00548_Well Construction - GW1_20230104

Jan. 29. 2018 10:58AM Env. Health : No. 6711 P: 1
WELL CONSTRUCTION RECORD L _1 Use Only: ,
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4.Date Wells)Comply ted:4 ? 6P,;4) WeR MN
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56.Latitude And lotrgltade In degreeslmiuutWiecoads or dedmat degrees:
(rfwaUgow.one lerltmtghsu6tcienr): 21.Cerlitlention: " p �j �a- f
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r T r �� etr�ed Well Comflin r Duo
6.NOW IbeaeUM10permen ent o Q empd my
Byi paing phi:form I Adre6y�,d..dar rho odll(r)wn(kept)eouraueud.b aecmdneco
%ro tills A repair to qa"Istingwa. OYes or Ma +ouh 1SANCdCO2C.0109m IM AVC 02C.0100 Will Connmrerrondraaaordr and thata
• {/rait4arepai,JJWaul:ww�weRoomnuamarnfaraarmnatrderpladrr6ermlunojrhe �FYojrldsrocoidDreupmrdalrothandJownrr.
r&pnirum&rfi21mwh shown ara,rho baekefrhurara,_ 23.Site diagram or adJifiaoat tiveli dctatls:
•L For GeoprobdDff or Closed•Laop Geotbardral Wells hdving the same. You may use tho back of thin page to provide additional wtn sae details or welt- -
em buctian,•o*I GI►1 is needed.Indicate TOTAL NUMBPR ofvzh conshuctiondetailL You may also attach Wtions!Qagba if ut eessary.
d»lled G/ SUBMITTAL IM URItCTiONS
9.Total well depib belotrlandaorttices ` (It;) ym,For all WeUx Submit this form within 30 days of completion of well
• FarmnuiptewenslirrarTdeprhrldf(fe�r(ematp►e.3®tOd�andi®!OP) cnnsttucdnntothefottowiag:J
IL Static water level below top of casing: _ (tt) DiMen of Water Resoumm Inforrmrtton Processmg Un%
JjwarerlavafttaboearnsFu&rtre+" 1617,1Zaitgetvlc6Cebter Raidgh NC27699-1617
11,Borehole diameter. (ta)" 2d6.For inlectton Welts: hi zddition w an&g tha farm•m the address in 24a
it wen consttnNldd method: A4nor i { above,also submit one eopy'of this fhm within 30 days of completion of well
(Er.auger.+US.eab►5 dares push.eta) constru�lonto�fopowing I, ,
Division otWater Resodreea�Ands tgrormd Injection Control&ogram.
FOR WATER SUPPLY WELLS ONLY- •18d Mail Service Centel•.RaIeigly NC27699--106
13a.Yield(rpm) For Water Sunnty&Injection Wilk; In addition to sending the form to
the address(es)alai,aim submit one copy of this fomt vvi a 30 days of
fib.Disinfection type Amount- completion of%ell eonstmcdort to ft county stealth depadiamt of the county
whtaeconswcted. _
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