GW1-2022-03682_Well Construction - GW1_20220321

n h LDENML WELL CONSTRUMON RECORD
North Carolina Depeemn a of Environment and Natural Resoums-Division of WOW Quality
WELL CONTRACTOR cm-TmcATION#:409-A+
is W ELL CONTRACTOR: f. DISWFECTION:
Sage Band Pump 'ves L.LC. g, WATER ZONESVVell {
F ln&idt"Hann
To From To .
Michael C.Sage From_To Fmn TO
Well Contractor Company tame From To From_To
STREET ADDRESS 204 Tom Ave 7. CASING: Th)dateasf
Castle-Hayne NC 28429 Fmn, 2 Two-aW Ft� 0
City of Town State Zip Code From To Ft,._
(910 , �,231-Mfl" Fran " To Ft_
Area code- Phone nwnber
L WELL INFORMATION.- 8. GROUT: Depth Material Method,
From_To= Ft �
31TEWELL10#Xam*came) / �1"�1 From To
F't -
VVb_I_CONSTRUCTINN PERMR#- C ALl) 'r]D -.lc��c 1 From TO Ft
- OTHER ASSOCIATED PERMITS(i W omme) 8. SCREEN* D Slot Sine
3.WELL USE( Allaham
Check pTicabls Residential Water Supply 9 FromQQTo in. �°Z In. L-
DATE DRILLED � Fmm__Y____To Ft,_M in.
THE COMPLETED AM 8 PM 1 Fran To R err. is
a.WELL LOCATION: r 1 10.SANDlGRAVEL PACK-
CRY:_�{.�1 Q COUNTY�_C t ►A Depth Size Material r"
//gy�pp rn1 From.td1� To Ft a (�c�L'1 I
g � Fron_' To Ft,_
(Street Name.Nm6ars,ConurBaity.Sub&jsiom Lot No..Parcel.Zip Code)
From i'a ,Ft
TOPOGRAPHIC/ ETTING: t
1 Slope a Val 1 Fiat 1 Ridge 1 Offm
(qwa IWO 11.DR&AAG LOG
t�►1t tuD>= r.__ � �From To MA R De=O*m -.
LONGM E _ in a dair a l format
I.A itudellongitude source. I GPS I Topograikic map
wort of wW must be shown on a USGS lopo map and
a#K*ed tb this form ffnot using GPS) 0 d Soo- —snM Va C KM
b.WELL OWNER - t+��� .I� •� '1
OWNER'S NAME Z
WPJFEf ADDRE J
t;ityorTown �� �a� � e
Aria cobe t �ember
12, REMARKS:
!ti WELL DETAILS:
a. TOTAL DEPTH:. L -
b, DOESWELL REPLACE EKIS71HO WELL? YES NOI rnotaEFMrcER"FrWKTnaswELr WAS oa+srauCreo watt
15ANCJiC2C MVBL
a WATERf,EV'EL Below Top of Casing-. 'r �� FT. RECORD w►S STANMRCS.AND. ACOPYOFTM
-
! (Use..+'if Above Top of Cadng) ! .. Q..
d. TOP OF CASINGIS��_FT:Above Land Surface' SIGNA OF LL CONTRACTOR DATE
'Top of w tem casing unated at/or below land atirface may require
a variance in hocordanoe with 15A NCAC 2C.0115. Michael C.Sage
e. YIELD{ypm} METHOD OF TEST \ i t PRINTED NAME OF PERSON CONSTRUCTING THE VYF.I.L
Sublftit the original fio the Divisiolt of Water Quatlily Within 80"days- Attn:Mfoimaa n Mgt.,
1617 Mob Service Center—Raleigh,-NC 27698-1817 - Phone No.19191733-701cp c;.:e'__