GW1-2021-02697_Well Construction - GW1_20210811

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_ 1 r ONRESIDENTL4L WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# oZ 5r'7l� /4
1.WELL CONTRACTOR: : d. TOP OF CASING IS !E2 FT.Above Land Surface'
N r r.4 'Top of casing terminated at/or below land surface may require
Well Contractor(Individual)Name a variance in accordance with 15A NCAC 2C.0118.
rr 4 ROL 4 (. �& L 4' '"r� ��j/t p: e. YIELD(gpm): S METHOD OF TEST 610W a J-v\
Well ContrYttor Company Name J A J
3S.a �Z��� �„� � �Q :f. DISINFECTION:Type r r,L 0 rt 11C[� Amount C1 Z
Street Address : g. WATER ZONES(depth):
N.C 2�1" : Top Bottom Top Bottom
City or Town State Zip Code :Top Bottom Top Bottom
( Cf/9 ) V9 7 -5—54121 ;Top Bottom Top Bottom
Area code Phone number Thickness/
2.WELL INFORMATION: 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# %��"L�J !� :Top L Bottom Ft. SD0721 e V4
OTHER ASSOCIATED PERMIT#('If applicable) Top Bottom Ft.
SITE WELL ID#(if applicable) Top Bottom Ft.
3.WELL USE(Check One Box)Monitoring❑ Municipal/Public 8. GROUT: Depth Material �-- Method
Industrial/Commercial❑ Agricultural❑ Recovery❑ Injection❑ :Top_)Bottom Ft.,61*1-16 h,�lA
Irrigation❑ Other❑ (list use) :Top Bottom Ft.
DATE DRILLED Top Bottom Ft.
4.WELL LOCATION: 9. SCREEN: Depth Diameter Slot Size Material
60 4&f.5- Top Bottom Ft. in. in.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) :Top Bottom Ft. in. in.
CITY: COUNTY/ ;601 IK t I^ Top Bottom Ft. in. in.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope []Valley Flat ❑Ridge ❑Other : 10.SAND/GRAVEL PACK:
¢/� Depth Size Material
LATITUDE 36 �I��� DMS OR 3X.XXXXXXXXX DD
�'
Top Bottom Ft.
LONGITUDE 7 °/� �.�rSr DMS OR 7X.XXXXXXXXX DD :Top Bottom Ft.
Latitude longitude source: PS aopographic map ; Top Bottom Ft.
(location of well must be st An on a USGS topo map andattached to
this form if not using GPS) ; 11. DRILLING LOG
S.,FAACCILITY(Name of the business where the well is located.) Top Bottom Formation Description
/
PJ Facility Name Facility ID#(if applicable)
60 4,-Ise7s' � �l S<S' � L a ✓i
Street Address 119 V d ZZ
A (41'S L 4 9 /V l \ L
City or Town State Zip Code / �
Contact Name
Mailing Address trp';1
City or Town State Zip Code : 12.REMARKS:
Area code Phone number
6.WELL DETAILS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
/ 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
a. TOTAL DEPTH: D RECORD S BEEN PROVIDED TO THE WELL OWNER.
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO/
nn I ATURE O ERTIFIED WELL CONTRACTOR DATE
c. WATER LEVEL Below Top of Casing: oC FT.
(Use"+"if Above Top of Casing) : PRINTED NAM F PERSON CONSTRUCTING THE WELL
Form GW-1 b
I Submit the original to the Division of Water Quality within 30 days. Attn:information Mgt.,, Rev.1 vo8
1617 Mail Service Center—Raleigh, NC 27699-1617 Phone No.[phone]