GW1--07825_Well Construction - GW1_20231208

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CO' UCTION RECORD(GW-1.) Por:tntemel VE0Onl + 'i
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5b.Latitude.anti Iongitude In depress/minutes/seconds ur dedmttl degrees: ' ' .- . .
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6:L(an)thewef(a Permaaeat or OTemporar3 stgtamcoefCeNtfetlwenConueetor:• • aam' • "
ti . Nlt algalrir thLs,ion►hereby cer*that the null(sj n mte)a(a eernlnictd In accordance •
tie this a repairto On erifugwell::• 011 Yen..oe:' " No wigs15ANCACOZC.O1OO or1SANCACO2C.0280 Well ConStniettnn Stardmds mud thug a
r .{fthief,orepar;Jul eetkraasr'taeil**Wistaria fasamtlon '..cplatritheawaresithe e45411Mstaetntdl 6aeitpmlfdadm trkasi+e1".11 r
npatruuderfal ireful lasectfonerlduthebadrejthirform.
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S.FortaprabPlDPT or.(9oiod-Iawp Gealhermol Wells havbigtha same
page 1 .
_ cansinktion,eniy'1 GW 1 isneeded:.lndicaleTOTAL.NUMBERofweRa ondetaiis,Yonmayelsoattachod iaual:Fa$eraifaecessaiy
Stiilil1'ITAL INS'41tIIcn(mlS
�' 9'Total well depth below *face:face: . • S. _ : (ft) 24a.por'All Wells: Submit this"Simi within 30 days of completion of well
1.
Forrsafdpte.arge tseaudeptlis(fd Threnl(emmyle'3Qd00'md2 t ®10o). ep gctiantothefollounng: ;.
a". 10.Static waterlevel below top of easing:.. 4 o (f.) Division of Wateir.Reso:rees,Information Processing tail,
' ' Ifmiterlevel leairavecusbi&use+" 161'1•MaliSermites.Center•Raleigh,NTC21694-1617
11.Borehole dioineterr b Cam) 24[e..jror nteeetoA WellQ:.Ia'addiilon to sending the form tithe address ia?Aa.
OM*also submit ono co of this foffi within 30 days of compietiain of wen •
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12.W eonsireuttan method conshtt�oa to the followia�
' ai . .toiury,caSeti tlitectPasb,elr) • •i, Divisions of WaterResam ,Underground Injection Control' rogratn,
Raleigh,NC276904036
FOR WATER SUPPLY WELLS ONLY: //�� 163611gaTi15ennce;Cedter, '
Ibl_.of test: _ke/404•- -24i+ b Water fiiDple-8c Idlectiatl Wells: In addition to send'ng the feint to
13a.'Yteld too / the a ddress(es):abovet'also sub*•One copy of this—font within 30.days of
�"�'O Amoaflh • /a-�•`- - coineelion of well conablictioii to the county health department of:the'county
136.,DIaWfectlon types wht ra y .
• NoiihcaiolinatipintovntoignvuonmenmlQOily*DivhionofWaterSem:1m s
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