GW1-2023-01686_Well Construction - GW1_20230214

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Facility/owwr Name Fad*MO Cn wlic") h. ft. —�--
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Sb.Lath and kmgitade to de lottl[[texhe conds or decimal degrees: —
(ifweli field,nee hwkmg is sidlick ). 22.Calfffieation:
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6.11(are)the wen(s6eratanent or QTemporary siege of ed WeiICo:a.cso, i
7.b thb a g Q Bp rigning this fa►+n.I 3'rarfyy that AN ua IN»errs(wets)cnw*wArd fa ocror+i ow
leNh g9 an esistln wen:, Yea oro »rth 1.7d NCAC 02C.0100 or IS.i NCAC MC.0200 RWl CanslraacNm St®wbr*ad that a
IJ's6tt k a^iFp6.j1tT a btorn wry toatArorUau button and apkin the nature q(the copy vItait Aker l lwe brut provided to the mvil owner.
rrvair under#21 rn;arks secr;o7 a.an tJrc bat of t?i fa a
23.Site diagram or addittonaiwedl d*tft
L For Ge optrebe/bPT or Qosodd oop CeothermW Wem having the same You may use the back of this page to provide additional well site details or wed
conaructian,onl;Y 1 aW 1 is needed. Indicate TOTAL NUMM of wells crosbuetiaa d3ewis. You may also attach addhionai pow if nwmaaty.
dfilledt 1 _
9.Tout wen depth below land snKace:�
lbr mrltok we&lid an depay y'd n(aampk-3®200'and 2@1001 (R) Ua. For All Wega: Submit this tt)ml within 30 days of mmplefim of well
construction to the No":10.Btatk water level brolaw tap of suing: 10 1)tvta{on of Water tiesatrre ffwaarr level k above ceeb,s,urn es,IMormadon Prooaft Usk
( 1617]bbO&erviee C;eafter_It%-Iftk NC?7699-1617
11.Bore+laole diameter: 1p (ter.) Kp,pM liia n Wet1a to eddttioa to
tom_ sea ft the form to the address in 24a
12.Wts eenstrucgon tuethod: Ir 0011� above, also submit one angry of this!nzat within 30 days of comgiet2mt of yvelI
(Le.anger,me ry,cabie,direct push,eta.) —"' eonstmaton to the towwb4g
FOR WATER SUPPLY WELLS ONLY. THv M of Wetter R arms,Underground Tnjexttoo CbatrW Program,
1636 Mail Service Center,Raleigh,RC 27tt94-1fr36
13>t.YieldWm) �-O Method of tart: 24c.For Water Soon v&lnlMft Wei In addition to leading the fhum to
I b the MI(fra s(es) abovo, also submit one eopy of this form within 30 days of
13t3 Irtsiau;zc t l;,u agile: r.r�aaiuC _ W construction to the catmty health deDarituent of the county