GW1-2022-09260_Well Construction - GW1_20221003

WELL CONSTRIIC4ZOPi UCOItD(GW-11 or use onlq
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4.Date Well(a)Completed: Wen ma / 57 tr.
Sa.Well Location:
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7.is this a repair to a exlst(ng well: QYes or 1S.tXG1C 02C.dh�m fl41VCAt'01C.O1C0 tYdlCounrcrtoaSasrxrsrotr sad theta
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23.Sate diagram or additional roll details:
L For GeoprobeMPT er Cloted•Lvop Geothermal Wells lmviog the aame YOU'MY RX rt:p bwk of this page to provide addit aW well site details or well
eonsou iOd,only 1 GW-1 b needed.bdieate 70TAL MIMM of wJb CaMMetiondetails.Yott may alw poach AcWl oW poW ifnecessary.
driucd SUBMITTAL It4sTRtf("fI�NS
9.Total well depth below land surface: d� fh) 24L For Ail Wefts: Submit this form within 30
Faamptp VO&furatldeprhs jd)7e>mr(a� 3�d• M andl®tdo') days of ea mpletlon of well
_ eotmntmrim w the following:
AStaftc wale!suetbelowlopofeasim -^f U ([t) Milan of Water Resoutten,InfornmtionProeesslugUnit
!/Marerterettrai+ovsaaiu�we+- 1617 Mail Service Ccdter,RAI*h,NC27699-t617
ILBtuselmis diameter. pn,) 24h.Fer Inl�lea Willr (n additiart to sendutg the from•o the addles in 24a
12.Well construction method. above,also submit one copy of this,fbtm within 30 days of completion,of well
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s do >^ t otwtntcaoaw the following
FQR WATER SUPM.Y WELLS ONLY: Division of Water Resoarees,%daground Injection Control Program,
1636 Mail Service Center.Raleigh,NC 27699-1636
lye Yield(gpta) Method of test J. Zia For-water Sonnty&Intccff a Weft In addition to sending the form to
the eddress(cs)above,also schatitiorie copy of this fame within 30 daps of
fib,DkWecdon ryes: Amount: C f compledon of wall constmction to-dm county health dtpem mt of the eo"
whoa eonahttcted.
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FatmGW-1 Nara.(krot�Dspadmest afEao;,oa,meauiQmiiry-D;v(sion ofWaarRcsounm RevisedZ22-2016'
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