GW1-2022-01610_Well Construction - GW1_20220201

WALL CONSTRUCTION REMBD(GW-1) Format Use Only:
L.welt Contraei or Informatioa:
Z. ARAYGIE4 1LwA3MR2DYM
wencontractamone IBM TO
1 Sg " 6j `� rr�
>�Wen a85' 30 0 A ,�-
15.0U1MC taIZG se164Asedwe®s tlRLMM
i ! > m las�leL
c nyrra� °- a 7 ./4 P."o G
16.IItl UR CASIPW�110)l1NG
2.wen( nPemittk 33� l5 1UM! I To I AMEM I TE >aazL
te�auapp de watt aoamadnowper a(ce tllG taoarrjc 3T�t vmc oral et 0. 1 is.
3.Wen IIse(eduekwM=* n_
water Sapplywell; i7.St�v
>ast>M m niee� sLors>zs nrsl>sieL
p a IL
(N may) ORS WA.Suppiy( ) tL M id'
Water SPPIy( 11L GROUT
hBt)i[ so atsaeieL aeetaurtr
NOR-WaterSapplywr h 0 n. m WVft Pe ex
Inje�n elb _ QReooveiy ff C) ffi t 8 iA. We
8. !L
19.SA WOMME.PACK
aid Rvay Ey Baines > m T* MA�AL' >�LAX39NUM i�DD
Test Q ML >z
Technoloff ❑ camAml IL IL
Geolhemml((3asod lmp) QTraoer 2L RuaAMLOG aadiFri a
f-p)mm>mdrrUl Rrmaft) ' To nor iat>�aihedc
S n. drf
nat�well(S) :. > ( : win.
sa.Wen Location:
FaesliW0wmr FaciliqIDg
C nr� cD5�4 010.xo
couldY P:a1�Tdr�Scaaoa� Na j ` .P• " ;':fi'r x
tI�
vrY(
56�LaSfade a�b»gdade m � �
eel wcn ficK am latem is sadfieieai) CA p 22.Cernfrmtion:
Aqft N 79- 39- J [ 1 W -
6.Is(are)thewen{sPetimaneat or [3Temporary Hof Weli s' - Daft
7.is this a re pair to an By this form.I hereby certify that fire wa(a)was(mare)oawracmd m acandmce
e>oafieg well: [3Yes or o wifir 15ANCAC 02C.0100 or 15A JVCAC M.0200 Wen Conx&m*n Shwulff 3t and fired a
lfdia is a repair,fin oat ibrmrn wen aoaaratRart mfwatatial e�f®t die"crane of*e Q ff afAm reowd has bemr provided to the wen owner.
repair wider#21 remarks sechan oran the bo&ofd*form.
23.Site dhW=or additional well deta0s:
L For GeoprobdD>rT or 009011-1,00p Geothermal Wells having the same You may we the back of this page to provide additional well site details or well
construction.only 1 GW-1,is needed Indicate TOTAL NUMBER ofwens aeon detlL You may also attach adffitional pages if necessary.
drilled
SUBMITTAL INSTRUMONS `
9.Total well depth below land smfaer: �g s ( ) 7Aa.For An Walla: Submit�is':fotm within 30 of
Foramleplewells/ataB�da Isl�(�.3�pp-��pp3 aomstrudion Well&'the Sib � completion of well
j»ofic rr' o loved belon lop of ending: � (IL) Divaion of water Rmoao m Isformatio n PM—h g Unit
"�one 1617 Mail Service Cater,Rabogh,NC 27699-1617
i
1L Boishote dmme tr: p 24b.For Weft In adder to sending the form to the addnss in 24a,
12.well m A 12 i\U/ iT ?j �°v�also snbmii amDopy of this foffi within 30 days of oompletioa of wen
CLG aver.�caw,daaxPask etc.) condractionin the fiullooring
D1vi sion bf Watw Resources,Upd d Injection Contra Prgpsm,
FOR WATER SQP1cLYwFddS�II.Y: 1636 Mail SWUM Ccutur,Rakigb,NCZ76994636
13a.Yield(gpm) cz Method of tip R _ 24e.For Water 9mnlv&bdeerjou Wells: In adfOa to sending flu Soffi to
the address(es)above, also sabmR one Copy of this �within 30 days of
1 .I/isint>x type Amo®t O Z Completion of well CmsRaction m;thc 000ait)t heaHh departmm2 Cf tha o�irgy
Where Cms$addt
FaunGW--1 NaahC=otmaDepw mcaofEaveammcmftiQmTuv-DiaisioaafWaeerResamos Bea�d2222016