GW1-2023-00984_Well Construction - GW1_20230118

Jan. 29.. 2018 10:58AM Env. Health : No. 6111 P. 1
WELL CONSTRUCTION MCC)RD fGW 1) orIntetae Use only:
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3.Well Use(checktteil age):
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_Agricuitutal QitittnicipallPablic Er n —---T¢ni L
Gemlrermai(Heatindrooling Supply) esld"Water Supply(single) R IL
_Indushidwommccew QReeWential Water St"ly(ahatcd)
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iVon•Water$upplyWcl► R . t ra
"""""""'M ❑Recavety tt � -
ecdon Well:
- Aquiferitcebarge [3GmundwsterRemedieticn
AquiferStorageandRecovezy DSalinityBerrier iiND i ==__K-•�c< .... ;;:
AquiferTest �Stamiwattr Draip2ge tt
&Ferimcmd TeehnologY DSuWdence Control & R.
Geodresmal(Closed Loop) ureter
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d.Date Weil(s)Completed:LE 3 Wit M#
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5b.Latitude and longltudtin degreeshninutedwoadt or decimal degra r.
• �J�.�«t oa q n�Ji� )N ��r � ��� � 22.CertfTicafioa:
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6.Ts(are)therveU(a)0ermonent or Memporm Sttlmro<eo ernfleMUCa tl or Due
By-OP ft I/#"fOrbt I hereby eff*rhor the tnlf(s)war(ws)emuftsrrd a,cwordenrn 7.D licit a repair to an eabdng well: 13Yes ,afth HAAVACOIC.OI00 ar lM ArafC o1C.0100 gp MConnmmfoj2&ft pxtr ondthar o
{(+Ids�frarepafrJiftmet+caw•�ldrwmt/ucriaArofaraialoGnGl/dmpl0a11hannitlNofdu �PYMdnr.umMharbsrupra+Ydu/rotl�rRlloaircr.
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23.Site diagram or additionst wall detaffs:
&For GtoprobetDL7 ar Clotetl.I oap Geotberatal We11s having the soma You MAY use the bask of+his page to provide additioW azll site details or well
emrsauC64 otlly 1 GW-1 is needed Indicate TOTAL.NUMM of vocas eOnstnteti011delaits.You may also attach additional pages if necessary.
- . dtillal:
O SUMTTAL iNSTRIt=r MS
9.Totel+vell depth blow Iandaadnar ( (1L) Zia.P°r A_11%Xd—': Subs 116��wigs 30
FormrJnphexsOsl+*talldepdu,Jdy/veru(emmp►e.1(�r00•oudz(tdtoa) days oPeompietion of well
�� coa9nvctianlothafollowing:
lU Stolle
t-01ft 00alhdowtopofeasing: (n) Division Of Water Rwourees,Infortnatlon Processing IT*
/jrsmerre+rltrabmaprrhtgora+- 1617Mai1SemceCehfcr,RaldglgNC27699-1617
' 1L,Bomltolediameter.�((n,)
- ?rib.For Lniec_ tt�n�VeIL In 4dditicat t0 9Cndntg the fmmta the address in?Aa
]Z.Well corrstracdan method: etso submit one copy or this toms within 30 dabs of completion of+vall
(L &Mc,MWY.cable.duns path,eta.) const:ucdonto the fanmving:
FOR WATLR SUPPLY WSM 4ONLY: D+VMm of Water Reymtrccy Ubdetgrodnd Weedon Control Program,
1636 Mail Service Centel,Raleigh,NC 2769-4-1636
13a.Yield r
(9131n) Method of tart 0. l rU' tic.Far Water Suenty&Inlecdan Wells: Ia addition to sending the form to
rho mwnas(es)above,also submit ant copy Of this form within 30 days of
13h.Disht[eedon types H AmountcO complttimt of%ell constmetion to ft county health dap warn of the county
• esthete conslrttcted.
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