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7.Is this a repair to an existing well: CYes or tVo 74.4\'GC D:C.OOP Or 11.1\CAC,TIC.n2Wf n'efl Conrnvcsv,r Standards cmi Owl a ices•
:I Ow.,a epan_6!:ow,bpi,.6,41,nn.rrv:„r,,nlfornarem and erpnle me w+yrr Al rn.• of01 r rerrvd ha..brcr pr it.dea Mai•r/l oonrr.
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23.Site diagram or additional well details:
S.For Geoprobe.'DPT or Closed-Loop Geothermal Wells having the same You mat use the back of this page to provide additional,well constrution info
cons:ncror.only I GW-1 rattachBox). additional pa c.if neces.ar
dulled. I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below lead surface: GI Y._5" Ih.1
he,nutnpv evil,fist'di Jepk,if drJ.re,rt("wren'',;;e:no 0M1:4,001 Submit this GW-1 within 30 days dwell completion per the following:
10.Static water keel below cop of easing:40 1ft) 24a. For ill N ells: Orisoal form to Disisioa of�Wate Resouxes OW RI.
- Information Processing[Ind.1617 MSC.Raleigh.NC-'0 6l
Ai'wM And 11 Area,a M„ea`,a.. -
2-lb.For Injection Wells:Copy to DWR Underground Iniection Con::ol IIUC)
It.Borehole diameter:6 1/8 On.)
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Program,:636 MSC,Raleigh.NC 27609-I636
I2.Well construction method:Air Rota'J►/
i,a.i a.Mary.cable.tined tusk,efe.l 21e.For Water Supph'and Open-Loop Geothermal Reluru well,:Copy to the
county en\:tontnental+het Ith department or the counts where installed
FOR WATER SUPPLY WELLS ONLY: 2-Id.Fot slater Wells producing user 1110A00 GPD:Coe to DN R,C °CL 1
I3a.Yield(gpnt) `Irthttd of test Air Lift i_ Prnml PIO•i.101.1A11 MSC.Rale'ph.`L 2 7f,vi.le l I
Lbs
Disinfection type:Chlor. Tabs 4mount: 1 1/2 Lbs
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