GW1-2021-04630_Well Construction - GW1_20210510

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rtpatr colder 921 rrasm:is saetian or an the back ofthisform 23.She diagrata or additional weft details:
S.For GeoprobrJDPT or Closed-Loop Geothermal Wells having the same You may use the bar1:of this page to Xovide additional sell consbtetioa lain
consauction,only i GW 1 is needed. Iodic a TOTAL NUNMER of wells (add See Over in Remarks Box}You may also sawl additkwl pages if necessary
dn7led L� 24.SUBMTITAL INSTRUCTIONS
9.Totalwell `
For mrdnpte,. aU dgala if m [e-mail]/d 2 p100') ( ) Submit this GW 1 within 30 days of well completion per the following:
10.Static water level below top of rasing- 242- For All Well=Onguml form to Division of Wabw Resomces (DWR:
1fWat-V k e1 is 4bVW CaSft:ffe„IIt.f/() won Processing Unit,1617 MSC,Raleigh,NC 27699-1617
IL Borehole diameter l� r a Cm) 24b.For Injection Weft Capy to DWI Undagrnmd injection Control ouc
Prog 1636 MSC,Raleigh,NC 27699-16-M
a W&construction method: A• J-
(i a.sox rotag,calk&edpmb,etc) -,-- 24c.For Watet Sntmiv rind Opea-L g Geothermn]Return Wells Cagy to th
county envuomm�a2 heatm a%=tmeni of the omity whoa mswed
FOR WATER SUPPLY WELIS ONLY:
24d.For Water Wells gre� over 1 GPD:Copy to.DWR,CCPCUj
13s.Yield(gpn> Method of test ,r
13b.Di Pedmti 2611 MSC,Raleigh,NC 276 26I1
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timfection type: Amonat: �
Foam GW-1 Nm&Carolina Dgmtmmt ofEn=nm: tal Qmbly-Divaion ofwater Reswaoes Revised 66-201