GW1-2022-03155_Well Construction - GW1_20220222

WELL Forhk Use o `.:-
L wen Contractor Informatton: -
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4.Date Weals)Completed: 1-1 1- 1- WeII M# R it
sa.�Well LLota�fiaon: R ft.
fG R
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Sib.Latitude and longitude in deg'eesfmmut iWseconds or dechnal degree: WMM
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(�weIl Se1d,one hdloaga sadfreie>rt) ' 22.CertiBration: + t ry e
3 36 L� x $lama .149 • W
6.Is(are)the welks): anent' -or ❑Tenipo 9 1 7 L • s aqp=�estined`Nen ".�' na,e
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23.Me diagram or addItiond well de Rar.
&For Geoprobe/DPT or Closed Loop Geothermal Wells having the same You may use t o backs of this page to pmo-ide additional well info
consttrtcti�,only 1 GW-1 fs neei a Indirlte TOTAL NUMBER ofwens (add'See Ovice M R,eniarls Boxj You may also attach addNoM pages ifnece,sazy.
ce:
dtiIled
tt11-- 24.SIIBMITPAL INSTRUCTIONS .
9.Total well depth below land sarfs T�Q
FosaarlffplairsIIrLstaIIdeprhrifd ( k-3(a)200'Z92gtoo� (� Submit thisGW-I 30 days of well tompletion per thefollowheg:
10.Static water level below top of easing: ft 24a.For Ali Wells: Original foxm to Division of Wetw Resomees (DWR),
I}+9 lenotis�ons -+- ( ) I (nPnocessiagUaiS1617;MC.Raleigb.NC27699-1617
11.Borehole diameter. f0/ gym,) 24h.Rot Tzktdon Wells:Copy to DWR,Tindaimuod lweetica Control(IUC)
hDFdm,1636 MSC,Raleigh,NC 27699-1636 ..
a Wen constcaction method: P 4 t a ki—A),
(z a ioeQy, ) 24c For taster SnDDI and Open-Loon Geothermal Retina Wells Cogytb the
:. couniy eavaoamesiat health dePmtMcat e��•-5w —msmed
FOR WATER SUPPLY VMS ONLY: 24d.For Water WeltsProdadngI over 1 GPD:Copy W.DWR,CMA
Liz Yield(gpm) �2,0 Method of test: Pamft Ptugtam,1611 MSC,Ralef C 1 11
13b.DlsIh&cdon type: Amount:
Foffi aw I
Noedi Ca=oSaa.Depatmmot ofFavaonmeotal Quality-Divmoa of WamrReswaoes Revixd 6.6-2018