GW1-2022-07018_Well Construction - GW1_20220725

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7.Is this a rgpair'to an erleting well: .0Yes oroNo with 15A NCAC 01C.0109 or ISA NCAC 02C.0200.Well Construction Standards and that a {i
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23.Site diagram or"adtiitiontdwell details-
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For Geoprobe/DPT or Closed-Loop.Geothermal Wells havingShe same You may use the baak'of this page to provide:adtlitional'well site details or well
oaM1ru&d0I only 1.GV✓-1:is needed. Indicate TOTALNUMBER ofwelts Construction details.You may als°atta°h additional pages ifnecessary,
drilled: SUBMUTAL INSTRUCTIONS fir!
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9'.Total.well depth below Land surface: f 03 (ft) 240.For NI VJeUs: Submit this form witivti 30 days of completion of well -
Fnrtmdllplewellrltr(alldT&ifdffonl[(erainpfe-3@`00'and2@100) consimctiontothefollowing:
10.Static water level below top of easing:. Division of Water-Resources,It forination-Processing=Uti t,
.yu&terlevel;k abaw castn9.are'+" 1617.Mati Service Center,Raleigh,NC 27699-1617
11,Borehole diame"..1 k 0%) 24b.ForIniection.Wens: In addition to sending-the�folm.to the.address.in.24ti
above, t: e also submit on coPY of this form Mi
thin 30 days of completion
Y of well
od: construction to the following:
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12,Well,constrnc6on.meth � -
rla Eger,rotary;czb/e,duectpos6,etc•) Divisi°n of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELD 01MY: 1136 Mail Service"Cente-r,Raleigh,NC 276994636
13a.Yield(gpm) Method oftest 24c.For Water Surely&-LtA-11on Wells: In addition to gend'mg llfe.folm to
the address(es),above,also submit one:copy of this form within:30 bays of
I36.Disinfection type: Amount-* completion of well construction to the County Health constructed. department.of the county
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Forni GW-1 NoA CmolimDepatttoentofEnvirommmtal Quality-Division of WaterResotuces 'Revised 2-22.2016
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