GW1-2022-04869_Well Construction - GW1_20220520

N RESIDENTIAL WELL CONSTRUCTION RECORD
C North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: H I 11'11
KEI j H, PRES;DELI f. DISINFECTION:Type— Amount
g. WATER ZONES(depth):
Well Corltrac ar.(IndjyidLla[Bam-el. , _ _, ,. __ __ 0 120 420 '10
=L)1VUl=Y V`JNILJH I VV L L &HUMH U1J., IN(:. From To _ From To From To From To
Well Contractor Company Name From To From To
STREET ADDRESS P.G'B0y,30'' 6.CASING: Thickness/
Depth Diameter Weight Material
From To Ft.
City or Town State Zip Code From To Ft.
( LJ28 )-264-2,651 From To Ft.
Area code-Phone number
7.GROU7: Depth Material Method
2.WELL INFORMATION:
From Q-_To45 Ft.Ce7neat
---- -- ----- ---- ------- -- ---
SITE WELL ID#pf applicable) ----- --- ---From----To —- -Ft. --- — ---
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 3740D &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply 0 From To Ft. in. in.
DATE DRILLED 5i`+,f2022 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM® From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION: Depth Size Material
CITY: rLp=l r+EKPyR COUNTY Watagi1a
From To l=t.
lot; CEhit H TERM'F-D OFIR"1-+�T It 421 OFF 105 E From _To Ft.
From To =t.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box) 01210 E{I'S T I(-.t_z WELL
May be in degrees, — 'I
LATITUDE 3 36.239051, minutes,seconds or 12n '�Fn _ (11FAfi1ITF
LONGITUDE $1 '749'�SIXF in a decimal format
:-,-rt din :aH.al
Latitude/longitude source: 0 GPS ❑Topographic map I xg;j -,P e h11TF=
(location of well must be shown on a USGS topo map and IKI gar, _ ,N i sws7
attached to this form if not using GPS) 5iin a05 _ tea ar,IITF
4.WELL OWNER
OWNER'S NAME( (-T�V:%.C'FIHT F 4 717T.T 7bNT _
STREET ADDRESSI-tilt; An P.j1T!=t:H.11i V k.;,V h l-,
VI i_..4 h7C' 226912
City or Town State Zip Code MAY 2 0 402?
(e]28) —406-{391
Area code-Phone number 5.WELL DETAILS: 11.REMARKS: j UN
a. TOTAL DEPTH: u45 1 CTDI%?T t7- 1?.() i r.12,ei 400- 510
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO�p
c. WATER LEVEL Below Top of Casing: 20 F. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUC N STANDARDS,AND THAT A COPY OF THIS
RE�RD HAS BEEN PROVID O HE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface*
*Top of casing terminated at/or below land surface may require 17
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED WELL CO TOR DATE
e. YIELD(gpm): 2 METHODOFTEST .biF f-fm7 t QQf=,r..lcl I
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days.Attn:Information Mgt., Form GW-1 a
1617 Mail Service Center-Raleigh, NC 27699-1617 Phone No.[phone] ext 568. Rev.7/05

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