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GW1-2021-00390_Well Construction - GW1_20211228
WELL CONSM CTION RECORD 3 NoithCatolmaDRufftnentofTmv andNaImalR DWW=ofWd'QwW WELL CONTltACTOR CERTIFICATION# 0-6 12 1.WELL CANTRAGT+OE� d TOP DF CAsM js --FT_Above land Surfaoo` n/ / 'Top of easing termed at/or below tend=Ab=may nawire i? n. 1`/� ./f:!� Sin -, f/'ti a ua eoe an a000rdat�oe vra 15A NCAC 2C A118. / Wen contractor(meat} e.YIELD WFG):�MEnWD OF TEST ATO L,1� / C�. •�c. DcSRiF�iTON:TiIPe - 2 Amomt even calmo b name ��,3 ctn-u z/ 9. WATERZONES(depth)- STREET ADDRESS Fmm-l-�-2 To /(o N From To n t= o7-7 U;-7 Front. i 9g To 3-D° mm--To- CilyfwTown State zio caft F n To Fmm To VJL7— S(VZ y - 7. CAMM Depth Dkmmw Tit whaa i AMR Cade- Phone MTdw 2.W©.LRAVft 1ATWW- F,,m—O—_To_1 Si F-�8 SARI i Nas7(--c- STTE WBJ-tD"vxfc2 te) F1om_ _ To FL WELL CONSTRUCTION Fmm _To FL- L GROUT: OePlh filft" Method S.tiitE L USEUSE(Check Appfie Eox) 0 . .GrnnvKC AgfiCUVAqaMReCarerA kdnrsrn From,_ To�Ft. hrt afte Oft 0 (m use) Imes f�L Fmm_,_To DANEDRIIJJM /a-:- cj- J- 1 From_____—To___Ft- zeta=c LeTED a-. D C AMO PIqt a sCREOa: Depot Diameter sesame ana�tat FOWL T in- 4�1lYELL LOP..�Tt01�CITY. s U:de- COUNTY loc�%N tiaM F To__ ar hL y 95 17 3 z o Ram To FltkL In. (Sgeet(+cane.cram6et�OommutAl/. .Ld No.P TPCod� 10.SANDIGRAVEL PACK: Sbpep � D RkVe 0 Odter D� �Site Maki (dmxk OP no W bw* Eror� TO O be Y LATITUDE �. /& • L , Ft,� - To FL_ a or From LONGITUDE [—��s I y�� madxiislfcnmet sow WGPS 0 Topographic map 91.DRQl9fG LOG �oa�on (Iocaffm afiwe9 mustbe shorn an a UP amp an S"0 d d ��° _ aVadted 6D this farm t3rrat trsotg CPS) - /y M - A , TrrcA.' c SrcneB /Ppc6( - b.FACIITIY-reteraaieaQtoetralrtecsr�etethe�reAisio "==Mfgapp- tte - NAME OF FACT AW STREEi-ADDRESS 1 Rc Ck arlbm State - zP Code �71fi>A a a. - � 1 v�UA►I' CONTACT PERSON o —�;— '"'o 6 - MNLING ADDRESS 3 X 7 (Pe An Re-idsyrI,AL rlc . 27_3za 12. cS: COt orTotm State Zp Code ( 3�(P ).. Es;.-- g7 I (P Aria code- Phm number tootEREIrCERMMTMVAELLwasaa w�tsuaNacootmaNCEViM 6.WELLDErAM 15ANCACZ ►VVULGQNSFM)CrM$T AMIMTACOWOr-IM a. TOTALDEPTM .2 Z neooau Pr"JMe1AlOTM%%lELLOWNM L. DOW WELL REPLACE EXISitlits WELL? YESD NO) SIGNATURE we.t CONTRACTOR OATS r.WATER LEVEL Belo+tr Tap of C �_FT QJw 4—pAbone Tap of Ca" PRINTED NAME OF 7 CONMUCTM11E WELL Sdbmftdmn �Woud to the Division cFVftlWQueWvddft 30 days. Ate Mtoi�on elgt, t=orm GW-1� lgt7 SM Service lamer-Rddgk HC 27W944H7 Phone lim f N9)733400 e3d SOL Rev.12W i