GW1-2022-03678_Well Construction - GW1_20220321

RESIDENY L'WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of;Water Quality
WELL CONTRACTOR CERTIFICATION# 4119-A
I.WELL CONTRACTOR: f. DISINFECTION:Type Amount
Sage Drilling and Pump Services LLC. g. WATER ZONES(depth)'
Well Contractor(Individual)Name From__To W From To
Michael C.Sage From To From To
Well Contractor Company Name From To From To
STREET ADDRESS 204 Tom Ave 7. CASING: Thidolessf
Castle.Mayne NC 28429 From _DTo Ft Dight
iameter e
City or Town State Zip Code From Tc Ft
91( 0 t.231-6669 From To Ft
Area code- Phone number
2.WELL INFORMATION: 8. GROUT: Depth Material
From To F �1e
SITE WELL ID#{d applicable) From To Ft
WELL CONSTRUCTION PERMIT#xf -O From To t
OTHER ASSOCIATED PERMIT#(d applicable)
9. SCRE Depth Diameter Slot Size e
S.WELL USE(Check Rppiloable t3o ): itesidential Water Supply U From To_ Ft _in. �_ in.
DATE DRILLED -I ' From To Ft. in. - in.
TIME COMPLETED AMU PM I From To Ft in. In.
4.WELL LOCATION: (r�r+ 10.SANDIGRAVEL PACK:
CITY: (► e11 COl1NTY �. From Depth
�d To Ft war �4vC I
asq W 1 � 1l;rL>> I �4_z l� From Tc Ft.
(Street Name.Numbers.Community,Subdivision.Lot No..Parcel,Zip Code) From To Ft.
TOPOGRAPHIC SET' NG: MAR 21 202?
B Slope VaIN Flat dge I Other
11.DRILLWG LOG
May.be in degrees, From To Formation Descripton a.^
LATITUDE. minutes,seconds or ` 4
LONGITUDE_ _ in a decimal format
Latitude/longitude source. I GPS I Topographic map,
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS) � f l�
S.WELL OWNER ^ M C-CVq(:
OWNER'S NAME \ '_ 1 �h
EET DDRESS I
+ e Q
/ NC-
itty�r Town/ Stag Zip Code
Area code- Phone rµlmber 12, REMARKS:
S.WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXIS71NOWEL YESI NO IDO HEREBY CERTIFY THAT THIS WELL WASCOMTRUCTEDINACOORDANCEWITH
c. WATER LEVEL Below Top of Casing:
15A NCAC 2C.WELL CONSTRUCTION Si OS,AND THAT A COPY OF THIS
j FT. REcoRD HAs TH
(Use.•+"if AIr Top of Casing)
d. TOP OF CASING 13 FT.Above Land Surface•
'Top of casing terminated atior below land surface may require SIG RE PFICE"FIM WELL CONTRACTOR DATE
a variance in ance with 15ANCAC 20.0118.(� Michael C.Sage
*. YIELD{gpm): METHOD OF TEST 11 I PRINTED NAME OF PERSON CONSTRUCTING THE WELL
r
i
Submit the ord9inal to the Division of Water Quality within 30 days. Attu:InfoilmtIbn Mgt;., Form GW U
1617 Mail Service Center-Raleigh,NC 276994617 Phone No.[phone] ext 566. Rev:3197