GW1-2022-00922_Well Construction - GW1_20220107

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M,Site diagram or odditlonat wail eielatls:
R-For CmnrahtttlrT or t lobed-)..nap Geolhermat Welb haVing dic saner You stay it zr:thr bock of this page(o provide addi6otlni well ills details ar tueil
unnminnainn,only I GW.i isneeded, IneticWTOTAI.NUMB$Rof-wpllq conitrurAinndclails. YOU May also attach$drlitionalpAgesifTIMMnty,
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'1.1ratat well depth 1►eifnv land surface: (C•) IlLa. ( CA WM; Submit thl9 thr►n Within 30 days (if c0M11111 ton of welt
I•rr Pn111f�J['�rrNt li,r nli��(rrht ffl enrnr(atnngth'-d(nVO(l1/�n(n�d i�alln0') cnnalrnction io the following:
I(1,9tatic wtttlx level below.top of losing: `� (ft.) Iliviaion of Water Rtmurera,Information Prommieg Unit,
(J e'afarG:+ellrrrh,rou cRdng,nlr "1 1617 Mail Service Center,itald$h.NC276".1617
t F.tanretrnte dtametcr:_ �� !�f (tn.) Mos.For raictN Wells: hi addition to:;ending the form to die addrom in 74a
17_1Vrt1 tonttrncllnn plethod; ul+nve,also s rm uhroh one copy of this fa -ilhin AM tlayc of complMon of well
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construetinn m the folinivin�
Division of Water Rtammes.Underground Injection Contra)Program,
IAA WATER St;PPF y wE1.I_S()VI,V: —T I6.16 Mail Rervioc Ce me,Stateio,NC 276094636
i.lq_Yield(gprn)T� 1Tethrul of test: 2.ic, r r t r Sammy etc ialggyon Wets: In addition to Sanding the tbml to
Nu: nddre.ss(cs) above; else) submii. one copy of this fort Within 30 days of:
13h,015in£ectitm iype: Amount, completion of+veil const—don to the county hcatih department of the county
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