GW1-2021-03561_Well Construction - GW1_20210823

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n ear raoder i 1 rcmnrltc xpuMn or em the hart:ajfbn jnrm• 31te diagntm or adlNtjaltat wall dalaliss
R.Mir Gt»prnhe/I1pl or Gaged-1 otip Geothermal Wc1in having lb"same You tun,Y use lite lack of this page to provide additional well 9ita eleittils or weft
mnstmction,onh 1 CsV,`-1 is needed. fndirxgq TOTAL NUMBER af'%Vclls
ronstnueliM details, You that also arch additional pages if Mecca MY
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�,liot�i well depth below tend surface; S()� _ } I ) �: Submit this tbtm 1Ylthin 30 dale of complt lion of welt
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10.Stntir watrr loci 1letew top of casing: (h•) Division of water Reanurtxa,Information p Unfit
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11.Borehole diameter: (in.) 2,t�n a�tnrliOO VYdW In addition to Sending file fOrm to tht:a UTM In 240
td>ove,also submit one copy of this faun wllhin 30 t#nys aF comple=km of wdt
12.Well construction methnd: � — - -- q)nstruclinu to the fallawitI
(i e,nngm-,minty.cable.direct hunt,ctc.)
_ j)tvlslon of Water Rtnpnftlt.R,Undtrgronnd itl(eetioa Contra]PirOgl'a1o,
fYftt WATER Rt;PI'!li WELLS ONLY- 16311 mail service Cenmr,Ralelp,NC R7k�•t636
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isle Xe iaiectl n WdIr In addition ttr sanding the term to
13a.Xirld(gpm) •---. ,- tllc oddrrss(es) abnv:. also submit{one copy of thig form Within 30 dtlyS �F
u3h.Oistnfect+og type: .Amotmt: completion of well wnstmCdon to'the county hmaltb depm=nt of ttic entity
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Dater - "off
Well Case: Well#:
Name: 1'2G Gt'� OjSjle�
Address:
Dump has been installed, well head ready for inspection.
Sign: w �^
Ctuwwv4l&r WaL Dri.(,(.i"