GW1--05359_Well Construction - GW1_20230818

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,// 21.REMARKS
County ParcelIdemi0cation NO.(PI ) Ir•t':-,rr_5t1i--n Prrkf-a.......:,a,,s a: „
5b.Latitude and twiglh'de in degreesl03nutes/scconds or decimal degrees: tQ/gO '
Orwell Bald,one Ira/fang is surck's* 22.Certification:
341 Pi LT? IT Z.c).76�2� w
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6.Is(are)the well(a) Permanent or I Temporary $igaansrc of fled Well Con6acmr Hare
By signing this form,I hereby certify that the urli(s)ens(stuns)constructed in accordance
Na with ISA NCAC 02C.0100 or ISA NCAC 02C.020a Well Construction Standards and that a
7.1s tilts a repair to an existing well: I®Yes or
If this isorepai,Jpl out balm well emuuu Uoninformation ed captain the nature ofthe copy of ofthis record her teen pwtdedlo the eel owner.
repair under#21 remarks seam or on the bads of thirfa nt.
E.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction d
construction,only 1(33Lir 1 is needed. Indicate TOTAL NUMBER of wells
details.You may also attach additional pages ifaiecessary,
drilled: SUBIVIIIrrAl..DIS"I'12UCShO,NS
9.Total well depth below land surface: 2.G�7 (ft.) 24a.For MI Weldor Submit this form within 30 days of completion of well
Far multiple wel&list all depths ifdifjerent(example-3@200'and 2@1001 construction to the following;
10.Static water level below top of casing: V9 (ft) Division of Water Resources,Information Processing Unit,
If runts?levet is above casing,use"+-- 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter ( (0 246.For Infection Wells: In addition to sending the form to the address in 24a
e above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: p construction to the following:
(i.e.auger,rotary,cable,direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 5 Method of test: ')49 kic 24e.For Water Suably&r Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
296.Dlsinfecdon type: 14-4-13- Amount te41) completion of well construction to the county health department of the county
where constructed.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016