GW1--06982_Well Construction - GW1_20231027

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WELL C0_1- Tit1UC7T_N•RECORD f__V_9) " . . .
For Use Only . " '
l.. el!Contractor Information: ' '
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Bunnly Well: '..
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Residential Water •� , .., ::" .' .: : •. " " . .. " . . 8t+pp1�:(abated):• >1g mtovr"-._... •• . . • • " " • "
NoI�ar at, ...:: •:Wells ..• :" • " " FROM " "D _ : " MATERIAL _ . . WCEMei�i'rMETHOD E AMom4r •
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(jeti}tila a ttPab.ltpoutlmaivn well ® ;pith 134 NCAC .Ol / Ny OTC.070D Fell Jwc116n Stm�dm�da and r .
if t hir a rc iai conrtrtmtlon fr ormaFian an4eiplafn the eaque grille co?y0' enecwid hasGxapmvtded to thewIJlonuirat
reinwkskeillenbran ihebaekq thliJarn,:
.. ' . • .23.Site diagram or additional well details:"tl.For Ceoprobe/DPT or GYused4;ooP Geodtetil;al Weli.hevhlg the ti6ne" :" .You niay.use the back of this into to pimvlde additional Well site details or well" " " " " •
constntepon.only l Otir•l is needed. Indicate TOTAL NUMBER ofwells construction details. You may.alao easel addit(dttl Pages iftucessa,
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9::TomlweDdi thhelowlaids yo75 " . I." E11�g' as Ua(9 tP n1e- 7oa•and7�ab, (�) ?�!or'Ul•We11 Sub this•form with•a 30 days of eompknlon of wall "
10.Stella withe level below to of Casino • . " "" canshuctIon bathe _ � "
diwwt Stale
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<ave l below tali fig. �t7 (It.): Divitton of Watetr.Beso Ini?ormatlon Pioees9lq$Utdt; -
• 1617 MailBervhee Canter,•Rglei$h,NC 27(199617:1L Borehole Montfort Cl) po,).
24b:For Intention'Wellsi; In addtticn.to sending the form to the.address'hi 24a
II.WeU cotutruction iDemaa;: { {� �� • • a•
bov6,also submit one copy of this fort within 30 days.of completion of well.
(tosuj4Know:eabla,direotpmb,eto) • COnettuctioatothe,followlri� "
FOR�V.. •:" -- WELLS ONLY: . " . • Division of Water Resources,Uadergeound Injecttoti Cantrul Pe+ogiann, . : '
13ia.Yield(gptn) `�: e . " 1636 MoilBetxvtce C®'ter,Ytalelg6.N76C 2 99.1636.
• thed Of • (•He in'4 Tthlu • 24e.Poi-Water•Sunoly&:Iniectiou Wall4 In addition tO sending the fon i to:.
. 4 .: the address(es):above;also submit'one copy of this foam within'30 .of ..
13b.DIiIafecfloa;typo NT1.1 "�� !©, • l(aeL ". cam lotion of well"construction to.t a•coon health
p ;bootydepartment of daysnty
whtancanstlucted:'
FonnOW4 -
NeuWCerolmal?enertmentofi�urimn btrb..ta.. nL.Z L__an._.__w. • ..