GW1-2022-09787_Well Construction - GW1_20221027

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MATERIAL
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Geothermal([3eatinglConlillg3upply) Residential Water SuppLy(single)
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you MW usn the tack of this page to provide addit-lentil well site deMils or well
R.Mir Gmprot!r111pT Or Claved4Lonp C,reathermid Wells having the snore you 4rraiL¢ You wayslse attach addllional pagem If rrecessery.
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t1.Val2l veil dcpt bglow land surface; __,( .) kln% forn,�k: Submit this femt'"in 30 an"'ofcompinlion or%vell
Am,nndNpre wMrlitr all A!Pr14c ifAl�Emnr rrsamply-3@200'and i@10n't conatnietion to the f01101vUt6:
In.Statie water level below top of caSing: —(114 DivifioR o(Wara Restrureah la%Tmediun Pmcmieg 1301,
frWaler•anal lr rrhrlru earring•une""•., r 161T Mild scr ike Ceater,Raleigh,XC 274"-1617
1L F19mhoicdiameter. LO �-00.) 2ih,ERE 1pInrtlnn 5VAW it)addition to sading thG form t4 Mir,txlOT=in 24n
/ t�/� :t119ve,also submit one copy of this form within 30 day4 of comidellon of well
12.Welt tanatrltellmn marked: ���` etmst uatian to the foiloWing:
(i c•alga,mnq,ct!hle,direct push,�xc.)
Division of Water Rent111rce%1in0er@innud 111jelLtion Cnalrnl Program,
POR WA't'CRSt:PPT-V WFUS ONlV: 1ft36 Mail Service C4nTcr•,RMclg1h,1SC:i!709-1636
13a.Yield(Qpm) l 12 _i�tethnrt or teat: x:tc Irnr L�'atcr Sanolu&Fn HAn we t� 1n rNidilitto to suixiing the i''mm to-
the addresses) above: also stibmit one copy of this form luiillin 30 days of
13b.Aixinfeerkm type: .Atmimr. comptction of%vdl construction to the courtly hoalth department of the 001101y
inhere eettsltnecad,
l nrnt GU.-! Nonrt l_mnlrmtl7iarrnttment"CI?!n-7rrinmcmtnl One111�-DivEnan of wow Rwatmxec ReviseA?.22 2Ri fi

Date: ~30 `�a-
Well Case: Well#: c�COI= J C)1DC7 Sl�
Marne:
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Address:'F 1 i f\� �W��
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Pump has been installed, well head ready for inspection.
Sign:
Ct e.&rwa fe r Wak D rriA.,(."