GW1-2022-03671_Well Construction - GW1_20220321

RESIDENTIAL W.LL cONSTRUcfiON BRORD
North Carolina DqartnnW of Environment and Natuai Remumn-Divisioa'of Wales Q= ty
- _ WELL CONTRACTOR CERTIFICATION'#4119-A
1.YYELLCONTRACTOR: f. DISINFECIION:Type A1ww* 1 i�7•
Sage Wrung and Pump Services LLC. g. WATER ZONES(depth):
Well Coroador ondnriduaq Name Fro,�To_ From _ To .
Michael C.SaLe From T_To From To
W ContractoreA Well Name From To From . To
STREET ADDRESS 204 Tom Ave 7. CASING: Thickness/
makdal
Castle-Hayne NC 28429 Fran- To -�- 6 FL r Q .f VC
City or Town State Zip Code From To Ft,
91/ 0 }2316669 From To Ft
Area code- Phone number
2.WELL INFORMATION: 8. GROUT: Depth Method
Nlaeeriai /( .
SITE WELL ID 8[fi appaeeble) From
From Tb
WELL CONSTRUCTION PERMrr# From- ^To_zQ it =(Y-44- 1
OTHER ASSOCIATED PERMMgff apAcade) 9. SCREEN: Depth D' Saeerm
3.WELL USE(Check Applicable Book): Residential Wad Supply 9 From Q_To !Ft br. in.. UC' .
DATEQRILLED !3 �J�'c� From To 'Ft In. _ in.
TIME COMPLETED,_ �.®O AMR
PM 1 Fes—To Ft in IA.
4.WELL LOCATION: I 10.SAND1GRAyEt.-PACK-..
COUNTY /CO`U
CITY: Frk�mTo FtC* r` Matena .
From To Ft �n�
(Streetrve.Ne Nmmera.cannigrdt.,SL60Wsion,Lot Narcel,Pa .Zip Cade) From - c FL,�,� 11 2 02
TOPOGRAPHICM
nNG
1 Slope 1vaneRidge 1 ORw - 11.DRILLING LOG
( ,l o Forrrwfth pesrnpfiori'�'`�
May be in degrees, From
LATMDE minutm wankel.or
LONGITUDE -- in a decimal 6mat7� '��
Latitndeltonol We source: I GPS I Topographic map, 1.a.
pocatim of wel►must be shown an a USGS topo map and t'
atlad►ad to this form•if hot using GPM
L WELL OWNER OWNERt g NAME S'+dka
STREET ADDRESS
( (�ftoTOWn State
�.31-gog�l ���. .• 4 •
Area colts-�Phone riumber 12, REMARKS:
b.WELL DETAILS: -6 w •
TOTA1_.DEPTH:
b, DOES-WELL REPLACE Das*nmG WELL? YES NOI
� l DO HEREaY CERTIFY THAT THIS WELT.WAS COl6TRUL'kED W AOOCrtCANCE WRN _
i5A NCAr=V11B.LCONSTRUGnON STANDARDs.AND TtW ACOPrOFTHIS
C. WATER LEVEL Below Top of Casing: FT: REcoRn wet —
(Usw*4:1 if Above Top of Castro) n -
d. TOP OF CASINGIS + I% FT-Above Land Surface' SIG RE ` Fl LL CONTRACTOR `.' DATE
Q1
'Top of casing terminated at/or below�[rd surface may require
a variance in accordance with 15A N C 2C.01Ia. Michael C.Sage
e. YIELD 1gpffly ;L METHOD OF TEST PRINTED.NAME OF PERSON CONSTRUCTING THE WELL
i
I
-� wq�
hin 30 days. Attn:IMorntafion Mgt., Foam GW 18
1 erk9yrS33RI!8R9 ot1 Mgt„ Rev.3107
`NReW,
"69a..617 Po.(878)733�016 @ ��P�raaa� Fo►m GW-1a
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