GW1-2022-09072_Well Construction - GW1_20220923

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Jan. 24. 2018 10:58AM Env. Health No. 6711 P. 1
WELL CONSTRUCTION RECORD(gy 1 t Use Only:
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L Well COnitruttion permit#: f ` DiAMR1RR
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3.Well Use(ebeekmil use): In.
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er8upplyl en:
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.WaterSupplyWell: a 2 ft.m Icoon ell:
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perimentalTechnology E3Subsidance Control imothermal(Closed Loop) DTtacerTO
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4.Data WARS)Completed:, 2 well uw IL
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By t�atag rlrit faro►I dero6y eff*Char die t►dtlA!rat Chart)atUMM d a aamdaaoa
7.Is tads a npalr ro an existing weu: QYaa or ®Ao wA 15AAVAC 02C.61W err IM IMAC 02C.02001raaCarrruoft&wjdtrob end der o
PAISisaF* ,JlRamhvwtwe?M&MCOIrhfwWianmadagofaa:rhenalen►tfdre osPYalft maw Ads 6MUNVOOto(ttrepmnw.
?V?Mrw*r'"IIUZL*amw a?an& ckOf ufarr,. 23.SRO dinrym or addiflos al adi details;
L For GeoprokMFr or aosed•Loop Geothermal Wells having the acme You may un the bait of this page to provide offiWand well site details or.veil
earn 60A,only I GW l is needed.ladicatc TOTAL NUMM of weiis couttuctiondetatlls.You may also onach additional pages if nxessmy.
dtigcd 11 SEM&MAL iNSTR tt"71f
9.Total well depth below land sndaces d ffL) 24a,pot All Welk: Submit this from wddtal 30 days of completion of well
>brmuurphndts/malldep:hr(/d�vrnrfecompla.3�7oo�and/t cmaCncdn tothefnllowi:{g: i
10.Stage water lest below top of (M) Div doa of Water Resources,Inibrmatlon Proccoug Unit;
gtararteeef mat oreexo8rg utt r U17 Mail Servlca Center,Mdo,NC 27699-1617
IL Borehole diameter.�(tp.) I at n&%
�- 24D.For inte�cil°�>tiNenr ht additions to the Imm•ou the nddr:xs in 29a
ellaemethod:AMY.9abtF doers prnit era) wt r above,also submit one copy of this form wid&30 dtys of completion of well
serest Mury:
12.Well uttuctiontothe*uwa*
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FOR WATER SUPPLY WELLS ONLY: Divtaloa otWafar Resuorcetr Underground injection Control Program,
1636 Nail Service Center,Raleigh,NC 2789-106
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i a.Yield(ePn)_ Method of 24e.For Water Supply dt Inkodoa Wells: In addition to sending the form to
the eddress(es)above,also submit one copy of this form within 30 daps of
Ills Didafeeden type: Amount: d completion of well constt don to tiro wmuy health depaaarent of the county
. wheraconsWeted.
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