GW1-2022-03685_Well Construction - GW1_20220321

RESIDENTIAL WELLcoNSTituCTlox RECORD
North Carolina Depummt of Environment and NatuW Ras wcw Division of Wdw Quality
WELL CONTRACTOR CRR-TEnCAnON# '� A►
is WELLCONTRACTOR: f. DISINFECTION:T3tpa Amount
Sage DrT ne and Pump Services i=. 9• aoNEs
Won Cortbactor(Indluidt�Name i
- FnimB�� To Fmm_-To
Michael C.Sage From To From To
Well Contractor Conway Name Fmm To Fin To
STREET ADDRESS 204 Tom Ave 7. CASING: Thkiatessl
QWneW Castle-Rayne NC 28429 Fmnm 81pTo� �� 5L up
City or Town State Zip Code From . To Ft
91( 0 }231-6669- F=L___.�_To Ft_ _
Area code- Phone munber
2.WELL INFORMATION: 8. GROUT- Depth IUktberial tlAeihod-
FromD_To F e 2 Pe � M od-
SITE WELL ID* appitcaae) `�,,��//� ��
WELLCONSTRUCTION PERMIT#rktk) -U(UXat-d©a Fran To . R
OTHER ASSOCIATED PERMmW ep ftW9) 8. SCREEN• D Dierrreter Slot Stbe
materm
3.WELL USE(Check Residential Water Supply 1 From _' �_ �_ in. .
,l@ �,Q To © Ft m UL
DATE DRILLED (� Fran 1`6 Ft,_M. Ut.�T
TIME COMPLETED OQ AM I � Fran To Ft in in.
4.WELL LOCATION: 10.SANDIGRAVEL PACK:
CRY Q�►'"� / COUNTY p`U lid V► _� Ske Mate�t
3 /—. (l'�� � Y T I ��Ct' ;q F��
Herne. Q Q F TO Ft1 �--••� r�
(Street Numbers.Carurnaily.Subrivisian Lot No.,Parcel.Dp Code) From To Ft f p
TOPOGRAPHIC i LAND SETTING: MAR 2 1 202?
I Sloe s Valley 1 Flat I Ridge I Other
(che&approprUft b* 11.DRLLING LOG
LATITUDE �'.b"6 de From To Fommtton
minutes,seconds or mw
LONGITUDE in a decimal format
—— - a
Lefituddtongitudesource: i GPS I Topographic map—
(location
� �
(location of well must be shown on a USGS topo map and 7�s—2 0 r -
attached to this form r7not using GPS) -
5.WELL OWNER --
OWNEKS NAME ( n (y)- Tom&
M-1Z
STREETADDRESS •\G-AA
r I I LXMP4 p . 8 yu
City or Town State Zip Code .
Ara cote-'Phone rwn*w 12. REMARKS.:
S.WELL DETAILS:
a. TOTAL DEPTH: a9 0
k DOESWELL REPLACE EXISTINQWELL? YES1 NO1 rno Y yTHAT THIS warwits as�aocotmM EWITH
c. WATER LEVEL Below Top of Cash FT 15A wEll CONSrRI�riOld ST OAMt'�THAT A DOPY OF TF�
(Use-+'If Above�-T1op of Castrrg)
d. TOP OF CASINGIS oC FT.Above Land Surface•
'Top of casing t ai;a-ted aWr bebw land surface may requim gfGNATURE OF SWTIFIED WELL CONTRACTOR DATE
a variance in bocordance wMi 15A NCA=_kt
e. Michael C.Safe
e.YIELD 4 pm):_ l.�.�METHOD OF L IA PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the 0191nal tO the Division of Water Quality within 30-days. Attn:htformad n Mgt.
1617 Mail Service Center---Rak0oh.=NC 27699=1617 Phone No.1918)7334b a ea:e=__ __