GW1-2021-02780_Well Construction - GW1_20210805

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L For GeoprobaN T or Cload4 oop Geothermal Wells haft the same You may use the back of this page to provide additional well site details or well,
co dmcdM only L OW-1 is needed, lndltme TOTAL NUMM ofwaiha mnstmodan details. You may also attach addlihmal pages if=eemmy.-.
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9.Tofat we11 depth below land aurthca: � [IL) 244a• FZ All�44altlarz Submit this form within 30�of�mP ledon of well
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X Static wder lwd below top ofcasfow 140 (A) Division of Water Resuura%Intormntlen Processing Unit
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1L Borehole diameter: (�•) UL For Yniectlou Wells: In addition to suing the form to the address in 24a
12.Weil coustrudon method: k[ above6 also submit one copy of this fbim%id&30 days of completion of well
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FOR WATER SUPPLY WELLS ONLY
Dhwan of wafer Resources,UndergioundRaleigh,
Injection Control Program,
1636 Mall Service Center,ll NC27699-1636
UL.Vidd(Spm) 3/LI Method of tart: 24a For Water Suanly&Infection wallse In addition to sending the form to
the addresses)above; also submit one copy of ibis *=aphis 30 days of
.13b.Dfdutieetion type:1114 W k Amouna ��nd7_ completion of wd1 eonwation to the ooun9y health dapartmem of the mussy
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