GW1--04124_Well Construction - GW1_20230623

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•• Sb.Latitude and longitude in,tlegreesholoutes/seconds or decimal degrees: l3is;Y)t � '''- •
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_ 22.Certification: '
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6.Ja(nre)the well(sj 1 ert,eaaeot or Temporary sp a CeniSe�ty Cano-aeror d�
Date
0Da7. thSSitCrm,I hereby SN that
Estsa repair toan=Ysgwell: es or ;e,i o IANCA0C.01 IACACO2CAWe1lCt cvo azd a
IfAiT!so repp�rillpurlarairn well wnutntototrinfbrnwrtaaandeapltrtaitltenamteoleo (WY Oil*recordhas ken Provided toeieurilowner.
repairrurdcr P,1 remarks argon or an the backofthlsfprm.
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XL Site diagram Gradational well details:.
. S.For GeoprobclDPT or Closed-Loop Geo-n,etinel Wells having the same You may use the bank of this page to provide additional even site details or well
construction,only.I,GW-1 is needed.Indicate TOTAL NUMBER of wells• constmetion details. You may also attach additional pages ifneeess drilled. aft:-
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SUBMITTAL INSTRUCTIONS '
9.Total well depth below hand surface: • .• �S
Formudsiwell ds'listal(deptTisiJcG,siufa(erample-420rcnd2C1005 (�) con•Far All Wells: Submit this(part within 30 days of completion of well
construction to the following
10.Static water level below top of casing: ce - I .
t o.St levellsabareo are (f�) Division of Water Resources,information Preieessiag Unit.
1617 Mail Service Center,Raleigh,NC276991617 •
1L Borehole diameter: tvv (be
246.For infection Wells: In addition to sending the form to the address in 24a
• I2;Well construction methods C�c s 1 �1; • - above,also submit one copy of this fora Within 30 days of completion of well
,sewn,cable.ttireetpush.etc.) construetiem to the following:
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FOR WATER SUPPLY ONLY: Division ofWafer Resources,Underground Injection Control Program,
1636 Mal Service Center,Raleigh,NC27699-1636
I3a.Yield(gpm) 56 Method climb t;a 1' J•L'1 e • 2410.For Water Sanely&Infection Well.I In addition to sending the form to
A a Q the address(es)above;also submit one copy of this form within 30 days of
13b.Disinfection type: ( 0/� Amount 1(,'I completion of well construction to the county health department of the county
where constructed.
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Farm OW-1 i
NanhCarolinaDell: mansofEnviroanu nalQuak -DvisionofWaterResumes i Revissed2222a1b
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