GW1--04212_Well Construction - GW1_20230706

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MATERIAL ElattACRMINrti[er9on
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4.Date Walks)Completed: r a_0/91 1D1f We11 . 0 /rJG `C 2'a✓ Cl41'
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Camay PamalUenti6 nNo.(PIN)
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Sit.Latitude and lohgllnde in degretslmioutey:aonds or decimal degrees: r•+a•s�•%.W1"s
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6.Is(are)the well(s)61Permnnent or[Temporary Sigar,maoCe?eni6edw►enCtinaacror Date
By al,1rbl,this farm I hereby aertb rimy the wB(t)uttr kre)ceOMtrcred,hi madams
e 7.Is Ms a repair to an existing well: DYes or EINo ,rid,"UMWinC.OI00 or Lit!RUC 01C.0100 Well Co tonS idardi and thins
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23.Site diagram or additional well details: •
8.For Geoprobe/DPT or Closed.Loop Geothermal Wells having the came " You may use ute back of this page to provide arldidmal well site details or well
construction,only I OW-I is needed.Indicate TOTA4 NUMIER of vas construction debits.You may also attach additional pages if necessary.
drilled:
\\ sOBM1TTAL INSTRUCTIQyg -
9.Total well depth below land surfaces oe (ft.) 2ta.For All Neva; Submit this form within 30 days of completion of wall
For mrdapkxdls hoed!el rfdJ/etanr(e e• 00•ami2 100) constmetiM ladle Wowing •
• 10.StaticSucherlavabelow top ofcasing: t R
: Jfuaterleasttrabmrcastswa+ ( ) Milan ofWatervlctCceesr Raltlgl,,NC roetsslugUnik
1d17 Mail Service Confer,Raleigh,NC276994617
11.Borehole diameter: 47 I/� (ht.)
ti / 24b.For Inlectlon Well: to addition to sending the Eamwthe address in 29a
. 12.Well contiruNlon method: PO l '( above,also submit one copy of ids form within 30 days of completion of well
f.Ma:REM�1e,dueetpat%da) �onspuetioatorhofollowing
FOR WATER SUPPLY WELLS t)IYLY: Dlvisionof Water Resources,Underground Injection Control Program.
cll� 1efl6 Mail Service Center,Raleigh,NC 276991636
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13rt.Yield(gpm) 0 Method dreg: j�.j}r.. For Water Sunk&TDlecdon Wells: In addition to sending the form to
13b.Dialnfeetldn types Amount: �` C G the addresses)above,also submit one copy of this farm within 30 days of
completion of well consttuction to the cowtty health departmeat of the county
whereeonshutded.
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Form GW l "NertbCmormiDepautel tatEav tanmased Qoaliry-DivisionafWetcrllwetam Revlsed2.22-2016'
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