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� 0 23.Site diagram or addrtioaat wen deiatls:
&For GeoprobeMPT or Closed-Loop Geothermal Wells having the same You may use the bade of this page to paotide additional well construction fi&
*MMrction,only 1 GOM is•needed Iadjrc3le TOTAL NUN BER cf welter (add'Sm Ovee is Remada Bout}You may also s ach additional pages jf neoemay.
drilled 24.SUBMMAL INSTRUCTIONS
9.Total well depth bmam law aarface: 3 20 c (L) Submit this GW-1 w M days of well eompktioa per the followlM
ForaaAok-e&,VstaII*.v datf&fenem(ezaarpfo-WOO and201M
24s. For All Wells: Origmsl fioms to Mvisim of water Rwwnoes (DWR),
10.Static water level top of easag: (S) boa Pmoossing Unk 1617 MSC,Raleigh.NC 27®9-1617
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1L Borehole diamete, ! a {m.) 24b.For Injection Welix Copy to DWR,L%dergamd ljectm Cadrol{IM
Pragrdm,1636 MSC,Raleigb,NC 27699-1636
11 wen conshwetioi method: af�T— /► ne - 2&For Water Stinals and Otxa-Loon G 1 Rtmn Welk Copy tb the
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FOR WATER SUPPLY WEI:LS ONLY: 24d.For Water Wens mtemr over 1 GP)1:Copy to.DWR,CCPCUJA
i A t r Permit Pmgtam,1611 MSC, 11
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Form GW 1 No*Cambm Dept ofr=v===;al Qm1AY-Divi m ofwamr R—
]tavisad 6.6.2018
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