GW1-2022-09793_Well Construction - GW1_20221027

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23_site diagram or ntlhlitlatml well dt:taila:
R.For Geopruhe/l/PT or Closed-Lanp Geothermni Wells having Ar same You may use the back or this page to provida additiomd well site derails or well
eon-91MCtinn,Rnip t C:WI is needed. 1'ttdicKe TO-fAt.AIUMBER of xclls corwiruction flelails. You may also attach additional pages if ocessary.
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9-Tolal'Well depth below laud surface: (I�,) • her AN Welts; Submit thla form within 90 doss of camplalion of mall
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florchotediameter: L 0{�(l�n,) 241b.ggr 1wIU9gn Welts: In addition to bending the form tp dw addrm in ZU
12 Welt rnnetnten0n method: 1�(�� nl?aM also submit one copy of this form within 30 dayS of COMPI xltut of welt
(i c.OUR-,ra P : --- �- T-r cnnstmctinn to the fodlowin�
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FOR WATER SCPP7 y WF;t L S ONLY: i)lvision ofWater Ream1rzes,Underground InjeLtion Control Prttgmiu,
tb36MAllSWVICe4CePMn Ratclgh,NCZ76996106
13a.Vteid(gam) _� „`Ulethtul of test: P 7fte.Itnr Witter Synod'&��,Qn_Welig: In addition to sanding the tlr n to
the addrcss(cs) above, also submit one copy of this fofm within 34 days or
13b.I)tsin eettoq type: ,Amnuat: CX)mpletion of well construction to the count)hoNth dt:panmeM of Iha county
where Conntmewd.
Fanrt CN'•i Nardi(Imltlm DeVInnment of 1511 i,damrmrhl Qlmtnty-Aioin,nn of Warcr lkairumcaa Re"hM 222 2M 6