GW1-2021-00558_Well Construction - GW1_20210224

02/18/2021 3:14 Phi FAX [phone] KIDD WELL DRILLING a 0001/0001
�••,�•s)1^ } ND_NB iSlCONSTttl1CT[ON� CgkD r� 2:4 2021
North Carolloa Duparanent of Environment and Natural Resourres•Division ft,
WELL CONTRACTOR CERTIFICATION#
1,WELL CONTRACTOR.,
d, TOP OF CASING 18 _FT.Above bend Surface"
"Top of Casanp terminated allor below land surface may require
W I Con``gtpr Qndhdduall Name `� avatianco in accordancewith 1$A NCAC 2C:011a.
-�( `J� � L.�„ e. YIELD(9pm) - J ' _ M8 MOD OF TEST r Tk
Well Contractor Company Nama f. 0 15 1 N FE 0 TI 0 N:Typrr' ' wt,4pArt aUat�,4
STREET'ADt7RE8& d 9• WATER ZONES(depth):
r, F� ��- o From �_TQ .
City or'i*wm� State Zip Code From b � Frixn__�____Tp
4— From—To Fmm—To
�e- hone number S. CASING: Thla 1.Knew
2,WELL INFORMATION: p W ' Material
Depth D� .F � D L
SITE WELL ID 4i(Ir eppliaeble) � ! From„,^To„�oo Fr. � 8. r'^�L,
STATE WELL PERMIT#(if applicable)a..>- p� s"p ,Q From___-,�_r To Ft._
DWO or OTHER PERMIT Frm ---- To FL_
WELL USE(Check Applicable Box)Monitoring❑ MunlClpal/Pubtle p.- 7. GROUT. Depth Material Method
InduatrlaVCemmarCtel L7 Agricultural p Recovery q injection❑ From 7pr 7'Ft b�A 0{�
IrrlgatlonQ Other❑ (list use) y FrOfR____�To Ft,��-
DATE DAILLEd /A From To Ft
AM 0 pM 2
TIME COMPLETED_. �c?
S. SCREEN: Depth Diameter slot Size Material
�_
3.WELL.LOCATION: From,,,._.,To- _- 'Ft_in,
CRY:�,7,�AKE- R 0 7 cnt)NTY jr From-__ To_,,,,_,_Ft.___jn, in,
dIM� : At-' From TO Ft,�_____In. in,
9. SANDIGRAVEL PACK:
(SUeet Name,Numbers,Community,SubdAi an,Lot No.,PR�eI,—zip Depth Size Material
TOPOGRAPHIC I LAND SETTING:
inslope aiey (_TFint oRidge Q other F"0'"--�-�?� Ft,
(Chock eppmpfieto box) From_To _ Ft._
May he in rlc Ft4m _�To Ft,.
LATITUDE ,�„ -pQ, l�i f 0.minutca„seconds or �^
LONGITUD> 29 From
l S S1- in R decimal fbiroat 1fl LINO LOG
From To Formation DeaGriptian
Latitudellongitude source: WGPS GTopographicrnap 4
(locaft of wed must bs shown on a USGS logo Mop and, °e!IICr
aftdchad rp this harm h'not ashig OPS)
4.FACILITY-Is the mmma nl the bwielcis where the well fe Iora10C, J7 e
FACILITY tO#Of appilobie) _ V
NAME OF FACILITY
STREET ADDRESS _
City or Town .+ State Zip Code
CONTACT PERSON
MAILING ADDR S„91$ T. LJATTE Mar
CKyofTwIn state Zip Code InIdD .901.RRY-
Arescodc- hone number a 't U a it ?�''U' -Ala+ t
S.WELL pETAIt.S- I 60 HEREBY CErtiih`/THAT tNl& ELF WAS CONSTRUCTED IN ACCORDANCE WnH
14A NCAd2C,WELL CONSMI! eTANDARIZ,AND THAT A COPV OF THIS
RFicoRn HAS OMEN Prep of o E WELL OWNER. /
d. TOTAL DEPTH:_,-,_Z�LLZ- _____---
tr. DOES WELL.REPLACE EXISTING WELL? YES O NO M-' SIGNATURE OF CERTIFIF D WELL CONTRACTOR DAT�
c. WATER LPVEL Below Top of Casing: (,-TFT. Sf ,, I � b D
(Use"+"If Above Yap of Casing) PRINTED NAM AF PE;iSON�C0NSTRUCoTING THE WELL
Submit the original to the Division of Water quality within 30 days, Actn:lhfotrtMAVOft Mgt, Forrn Gw-lb
1617 Mall Semice Center—Raleigh,NC 17699-1617 Phony No,(919)733-7Ci6 ext 668, Rev.7105