GW1--05811_Well Construction - GW1_20240926

WELL CONSTRUCTION RECORD For htemd the ONLY:
This southcan be toed for single or t t°Pk tea
I.Well Contractor Information:
Rex Meadows t4�A' ZONES i
Well Contractor Name ft. n V To DaSCIOPTION __
2113-A ff. ft. -
NC W.tt Corium for out irwAtion?Limbo i is.OUTER CASING(far audit- d- Maki*
Clearwater Wet! d)li#It {fib. -rAt.90s fc."�c+_.,.- ..-4�. .L,i grr•-u4y.tfftcxiixs MAT_autt..�`
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art
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List ad tgplicottk nril caastraelian perm-in.(Tutu County,Stale.Garsatce,etc.)
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County pnroet Idental.ation No.(PIN) -- 7
Sb.Latitude and Longitude to degrees/minutes/seconds or deelmni degrees:
(if well field,one lattfong is sufficient) ClIC R:
s'- ofCmteiucl Well Contractor = ` pale
6.is(st9)the tfeti(a):APormaneut or CJ Petnperiry 'thb furor.I hereby eertl[o that'the nei(s)roue(weer)constructed to accordance
�� With 1 SA MOW D:C.010D or ISA NC4C 02C.020I0 Well Construction Standards and that a
7.is tr3s a repair;e an exkilttig weft: D O l Yes or a copy of this record/we been provided to the will owner.
IJ i1iOre.. it_fin.',qksesseIH..ti,1?»,;trN!iKhten*.woioitgi,iwe4p are ti4hsce(lithe
repair Lander All tenant:secfian or as the back<phis farm. 23,Site diagram or additional welt delai u.
You may use the tack of this page to provide WMtier:al well she detarts or well
B.Number of waits constructed: constru.}iot details. You may a saAt3eh at .riGA}- z is if re rx352y_
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S.Trio wet;(r beln y feed sarfaee: fv_J 4ft,) 24a. kpr.„tilt ia/ Submit~this torsi within 30 daysof completionl of well
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11 0,....�..4 ,tl......*- _,y._ .i...'..Petit. UM. scar tnlrat ae Wallet In audition to scndina the form in toe address in 24a
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.4 I the ttddt4Sges)abObe, also submit one copy of this n�orm within 30 days Of
.'..`• .rn:��. { cconviction ,,.
of well c nitroctir to the ctimly health -rlrimcrit of the catrty
Form itW.1 Noma Carolina Uepa,-it1ic(.4 o1 covuo0ntent eou tianlra.'KC%Oweci-Uivlbiol.or Water tjuality itecitc4 an.n)i3