GW1--07168_Well Construction - GW1_20231101

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. 7.L this a repair to an etistlng well: • Yes or dbla/ with Ile MAC 02C.0100 or lira trife 02C:0200 WdiCeenntutaa57aadords ad Meia
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23.Site diagram or additions(well details:•
' 3.For GeoprobelDT''f or Clond•Loop Geothernrwi Wells hiving the soma You may use the Deck of this page to provide additional well site details or well
conswetion,only I 6W-1 isneeded.Indicate TOTAL MlM M dwells consttucfondetails You may also ettech additional pages ifneoessury.
drilled;
SUDM11TAL INSTRUc9N$ _ • • - -- - - -
9.Total well depth betow land names 01.s-
9.T You'd
�J ��71 r(e+amptai®too,andli�lOtr) (h') 2le. For Alt Welts: Submit this form within 30 days of completion of well
` I� construction to the following
wuet
10.Slade •Ievelbelo,v top ofcasing: ` G (rt.) DivisioaotMaterResources Information ProcesstugUnit,
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Ifsrmer had it above caesium+"
j� / 1617 Mail Service Center,Raleigh,NC27699-1617
11.Borehole diameter. • (9 14,,1 (ln,)
14b.For Infection Weus hi addition to sending die furerto the address in 24a
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12.Well construction method: Pau. above,also submit one copy of this than Within 30 days of completion of well
(i.e.w8a.rotary,cable,direct pub.eta) - censtmetton ro the following i
FOR WATERSUPPL MILS ONLY: Division of Water Resources,Underground injection Control Program,
r 1636 Kid Service Code,Roiergh,NC27699-,Gi6
13a.Yield
(EP►n) *-1Nand of test 4. lire.For Water Sorrily&7nfectlon Wells: In addition to sending the form to
• 13b.Diffitfeetlon type: � /� Amount: �adzes)above,also suit one copy of this hum within 30 days of
completion of wall construction to the eowisty health department of the county
wham constmcgd.
FonoR 1 N pl'ar0thOuoriaaDepatteat10 mmnenmlQmLr3,-Divlsiaeat'Waterltaamees
i liavisad2•22-2016'
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