GW1-2023-02752_Well Construction - GW1_20230417

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5b.Latitude and longitude in degrac tinttteslseconda or dpriroat degrees:
1 Of well field,elm s sufficient) 22.Certification:
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Sigma=of Certified Well Cantmetor Date
6 !stare)the yretl[9) PErroanrve or TiTcm pox.*Y By Signing this famr.I hereby car*that the well(s)Inn(ware)constructed to accordance
as No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that-a
7.)s tars a repair an cart tint`cdell: I�Y4 copy ajtltls record liar hem provided to the well owner.
Jfgas�a repots,fell out ia:ovr7 Mil eanstnc='Gan irrforcta";land explain the nature of the -
23.Site diugrram or additional well det 11s;
rcpzU under 021 remark;section Oran dseback�d u ate• the same You may use the back of this page to
ptuvida additional well site details or well
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S.n For Geopt oY frL or Closed-Loop Gtotite rmnl Wells having canstmetian deimis.You many also attach additional pages if aeSit edet
eonst action,only 1 GW-I is needed. Indicate TOTALTVU1VIBER:ofwells SIItiNd>1�1PA1 IIVVST1idIIC77L®INS
drilled: pp
2.2 ) ( -) ?Aa.per All Wells: Submit this form within 30 days of completion of well
g Totu)well aleglit Ftelatr land carfare: tc 3 ov'and 2@I(!U) con trttatiun t)!I he fnflowing.
Fartnuldpte txUs list all depths tfdtffer�rt(e�aa+P @200
of nearing: f (f") -IIivreoFWntarResnurces,1eefc.i ttoo 'r cessini unify
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(7 fin.) 29b. aF gr gpi)YTelts fn addition m sratding the iartn to The uddre .roar 24a
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