GW1-2023-02336_Well Construction - GW1_20230331

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6.Itr{yrc)die wNt i 7K • 1 i /.1( Pa'mattrnt or Q!7't mjxl2-1 (o- 23
\ !ta tore, Mod well C."!'.;'.7ator
?.le this a repair man existing Ivelt e
i Ir ur y:�err/tdln,>1JJ , weihroaanicf�-t hn ra/o N� AY.agra g der farm,J heathy ran*then the mMt/N NM(wov)cattnivdel&a awardance
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8.iror GeoproiNppp or Cf 23.Site dlsssatr or ttddliiomi welidttgrk:
I oe rta eopr,be I GW 1 is p Geothermal Welk having the name You may use the back of this p to provide dn7ted� MONO TOTAL NUMBER afuxlLc construction derails. You may else attach add)tio*Miami wed site da�7t or well
and • 1 pages ifrtacetsaty.
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-.10Ja(raasI tt1 7+q For AN W
111 St�e�e wader tlii: Submit this form-within 30 days of completion of well
love!betaw top of cssitrgt roasttoctian to tare f0llotl'1ag;,
`� Division of Water Aeeotu'eea.laforntpttent
t 1.S4trhotedirtttu�er. I 1617 Mall Service Center, 1 Wt.
�ti) Hb.IVC17699-t617
the fonts to the address in 24a
11.Borehole
holet►pMjpp 24b For isiecnm..r.._ to addition to wadi
a a age.mtaty,table,gaped mob.ace construction the fofhnvahoy;Mr Submit one i opy of this feria within plays of completion ofwell
Division of Wa et'Reamer UOdeigl and liVectipn Conlin)Program.
DOR WATER SLPPLV WELLS ONLY: __SA__
13e.Yield(gptrt) L 1636 Matt Service Center,Raleigh,NC'276904636
Methati afters: 24e for Vt.gp_EAtta•±u p e tectio_rib btatnfccMton type; the address(es) ab0 ferny at addition m smiling 0 Palm f
Amotntr completion of wdl construction to the c County h this foam within o 3a ears county
Form GW-t where tx»taancted• County health department the otuatrtty
New CototinuDoPortolootoft orkiiiihentnl Quality-DivisionarNatet Resources
__ + Revised2 22.201b