GW1--07788_Well Construction - GW1_20231201

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You:nay use Use buck of this pope aa•provide additionwt wall sit.dots&or wen
I.Numbs:of*sib construct/4:- c't uttc:.on details You any also attach additional Mill itbrassary •
fir waunte a.fecrew..ir w.e..st.,paysiGr wells GN 7 rac4•he trove t.rvwaw..Gowan. I '
Mi.�•,.a)L.r• WZ}W'CI'AL INS'f12(TIONS
f.Total wtD dlsplt/below load sodas,: �,4(9 ' iftj Ili. rem All WS((D: I Submit ttxa tiarnt within SO days of autpi.ii.n at wt.)
Fs ie4i*wrest un ell Itep .1(/(f...au(v,wwir•and'end KO1021 caut:t:rlion le Ow following:
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Drrisios of
ta k swirly/II hots*up of casing: iRI Water Qualify.Tnformstioa Truccsalag Voir.
7/r.,.,kw!is air.«MO let awe'..- 1417 M1i1'tlSrwiea Couic,Aalalib,NC 3l0ft.Jd17
1t.ame►as dimmest: `r-.. ria.i "Alb.F topic' &Nero: In addition to pending he!Om to the sddgsts to:ea
/J ore I. I IL;.bt• .:cn., of •.c n. • V twao .. days of samplrwn of well
12.Walltosstructiss sa.•__.• ____/ f' " // lf..jct ry c ng .c:, •. .n fatowin,
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FOR WATtfA tVUPPLY M WILLS
ONLY: / 1f3G ail Simko Comsar,Aa1.1gh,NC 274S3.143i
13a Yield(-a) ,c� - Me,:.ad st ust. a(,v '(4 W h 24a' Wei.,S t`i It Lucetlo7.Wells: (p ad Ilion to sooili4 the Corm to
INrdAsu(sr) above; also submit one aooy of this form witttO, X dart of
13ts Dislaktttaa'b•pe:C 11 L.G>^d At P Amount lb
l /J- tcr'plsLotf of well construction as tho county health depaioocrtt tS'►a:cwc+
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