GW1-2023-01992_Well Construction - GW1_20230227

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3.Well Use(check wen use): n h. !a.
14'Geothexinal
merSupplyWell:
FROM TO MAPMER SLOT T ! MAT ML
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IR tian FROM TO MME L LHPLACLHEMMEMODAAIII-Mr
n-Water Supply WCIL O �. ' `rUt• iMonitoring ❑Recav ectlon Well:
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d a e-t pd
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5b,Latitude and lotrpttude in deEreeslmlauteslsecoads or dedmal degrees:
+fwaliOeld.=11008issuSlckw) 22.Ccrtitrcafioo:
6.18(are)the tvell(s)OP"catment or OTeraporary Sigmnueot:Qtrd&dWaConoacror Date
,� By tlgning+iris far,n 1 hereby eeruy thin tha xeli(t)um(kere)[outltuereti�)i aarordoace
e 7.Is this a repair to an t4sling well: ®Yes o zo wi,h IJA kC.tC 02C.0100 or IJA NGlC 02C.0200 Well C08Ort,Wll Slaaea,d,and t&,a
(/rlvr is a rspaf,Jffl ar+beo�r+wdr ra�v[.uc+;ae IxJanmria,m,d etpfom rhe,wlrar ofdte copyojrhta rom,d has beau protrd[Aro rhe:vap owner.
rrpair vtider112J reamrh t[c11Gt orou the barkofrhrsforai.
23.Silo diagram yr additional well details:
8.For GeoprobdDPT or Closed-Loop Geothermal Wells having the same You may Dso the beck of this page to provide additional well site details or►yell
construction,only I GW 1 is needed.lndicato TOTAL,NUMBIIR of%ells constmcGondetaits.You may also attach additional pages ifneccssary.
drilled:
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9.Total well depth below lwda :- O A) 24a. For All Wells: Submit this form within 30 days of completion of well
rpte•3(�700•and2�lDp) canstructiontothefollowing
10.Static water levct below top of eAsing:_^, (h) Division Of Water R If r Resources.Information Proeesstu ffwmerletrlttaboievubigu+a+" g Unit,
1617 Mail SerVke Center,Raleigh,NC 27699-1617
11.Borehole diameter.
(J / 24h.For Inicellon Wells: in addition to Sending the form-to the address in 24a
12.Well construction method; /�()`FGt Y'fit' abavc,also submit one aapy of this fblm within 30 days of completion of%roll
(E.auger,rotary.cable,dotal put%e10.) - - construction to die fallowing: .
FOR WATER SUPPLY WMI S ONLY: Division atVater Resources,ilndetground Injection Control Program,
[ 1636,Nfad Service Center,Raleigh,NC 276991636
13a.Yield(gPM) Method or test: r t 24e.For Water Sunmiv&Inleetlon Walls; Th addition to sending the!min to
the address(es)above,also submit one copy of this form within 30 days of
13b.Ditlttfcetlae type:-- Amount:
GlYZcompletion of Well construction to the•cotuity health department of the county
where eonstiveled.
FormGw--1 NoOCmotioeDeputmaar ntEm•;maarearalQualiry-Dh*ionofWote[Rcsourtm Revised2-22 2016'