GW1--05358_Well Construction - GW1_20230818

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i 'cultural .'Pater Simply S�JeFI:•. I1 SCREEN
- . moor ''TO.- .._.. DIAMETER Hwy ETEE THICKNESS MATERIAL
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Geoth l(Edeatinclmg Supply).ERcsiderdial Water Supply(ogle) -
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Induatcla/Comlaclaal Residential Wtucr Supply(slimed)
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Nm�-Water Supply Well
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ty FROM TO ETATIIUAL EMPLACEHRNT METHOD
erTest QStonnwaterDrainage ft- ft.
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4.Oate Well(s)Oimpleted: 7/ 7 -2 we1ID# 1 4 ft- So 6, ?)-0C/1/1.
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Ea.Well Location:
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County Pareelldentifie tionNo.(PIN)
5b.Latitude and loagitude in dees,reesimlontesfseeonds or decimal degrees:
(if well field,au lestoag b cvfficieat) 22.Certification:
stsnnnao o ticd Well Coate elar 7!'23
6.Ic(ere)the vrell(o/J�)j JPermanent or Temporary rk e,ub
By signing this farm,I hereby cent.that the miffs)ens(ewe)constructed in accordance
7.Is this a repair to an existing well: C3Yes or ONG with ISA NC4C 02C.0100 or ISA NCAC 02C.0200 We!!Construction Standards and dun a
phis it a reydr,Ji11 out hstowi well consinwlion injamrattanxplain the nature ofthe a3pY ajthis mamrd has been provided to the evil owner.
repair under#21 remmbs seam or on the back of thisform. 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed Loop Gc0tltcrmal Wells having the came You may use the back of this page to provide additional well site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of welts eoashuction details.You may also attach additional pages if necessary.
drilled: suswirrra INSTRUCTIONS
9.Total well depth below land surface: 7.95 (ft-) 24a.For All Welts: Submit this form within 30 days of coin letion of well
For multiple wells list all depths ijdtgerent(ermnple-3@,200'and 2@l00) construction to the following; p
10.Static water level below lap of casing: Gi (fit:) Division of Water Resources,Information Processing Unit,
"natter level is above casing,use^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: r r-r-y above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,able.ditat pleb,de.) construction to the following;
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 BPhil Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I O- Method of lest: 41 24c.For Water Supply&Injection Wells: In addition to sending the form to
I type: Amount:
3b.Disinfection e: (`� (ailZ the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-I North Croatian Department of Environmental Quality-Division of Water Resources
Revised 2.22r20 t 6