GW1-2023-02437_Well Construction - GW1_20230404

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'' �� 'RESIDENTIAL WELL CONSTRUCTION RECORD
j . -- -• North Corollas Department o€ vaat�RandrlanaralR -Divisi�ofWatsrQu�ty
1.- ' WELL CONTRACTOR CERTIFICATION# a• � la- J4
1.WLa.L CONTI ACTOlb d.Top of Gam is 1 1/ Fr Above Lend&dace
k n. Ph :il; S/ ;it% 1Top of d attar bare land surface may rye
a variance in accordance teeM)15A NCAta2C.0118.
. Wen Ozed arthr(Ia eeklhral)I�as,itt e.YIELD(Spin): 3 C METHOD OF TEST A 474,7
t9 r lA://v Ste+:f� ideal ed. .2-C•Lc. L _-iype # `Tf/ Arnow* 2 eEApS
Wentorstractur Mnswy Name
STREET ADDRESS ak. .+1.a.t.zJ lege g. INKIER ZONES(depth):
From /}H To /`./5 From • To
c-/t.,ell n h /'1 G. .7-7Ggt-7 From 1'D To IV .From To
OW Toam State Zsp Code Fmm o To al • From To
Areaaxle- Phone numbernumber��-3� V yZ/ 7. CASING: Depth Diameter Ttu� Material
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2.W INFORMATION: F O To 9) Ft, 6'i'' -Si)1 gZ.1 ,�`!e- i�
SITE TE WELLWELL ID Sriapp6catte) From To Ft
WELL CONSLRtICi'EDN Paulti 3apprzahlel d Sr P From * To FL
OTHER ASSOCIATED PERMIT trtifappRooW ,, "'RCM Material Method
3.WELL USE(Check A Ole Box) gU fkrictpaliPulfal
IndusbialiCommerciati D From 0 To a-0 ' FL PP kbAaped
Irrigation] OtherG (ON ttse) pr aee'S 7�'C. F�___TO FL 'K f i)p rtS '
DATE DRILLED 3.-1(s�- -7-3 From To FL c/
TIME COMPLETED `V: `-/ MOshe kes 9- SCREEN: nit, Diameter Slot see Material
4.WELL LOCATtCNI: To uh.
CI1YJ 14 vv toa, i SO let COUNTY `r From To in. In.
//0 O &A b r.YP� l�d. � �5 7 " From To FL in. In.
(Stud Nta os.Numbers.Coramimily.Sulrfutzion.LotNa.Meet.Tr9Code) ELL SAMlGRA1lEL PACK:
TOPOGRAPHIC I LAND SETTING DepthSize Material
D Shope 13 WWI D FdaVB'itlrlge U Other Ema4 To 1 £ FL
(chock ? Maybe in filirces. From To '� Ft
LATITUDE• /1-1�v a'6' ' 6.La' mints,seconds or __ TO FL
LONGITUDE L✓Lae o3. Sot`f inadecimalformat From
• Latitudellongit Latitude/longitude soimce ciPS ® Topographic maap I1.DRILLtiiG LOG n Damon
Meehan oft must shown on a USGStap e imp and From To � ��
•attacherltoiMisruarffantusng.GPS) 0 -
,s-- O 0 r0 col,. Sc-is,
Sa- k4 /3r-P.✓, c5e,A,et' 6ra-,/c.
5.FACILITY-bum rarnrr taeraa rt erraisb S( fa". ;G -Z z G f� 1C j
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FACILITY ID Ofapp .%) . -
NAME OFFACILITY 'A' •
, , • ` F ,• xa 11 _ i,.
STREET ADDRESS
. APR J 4. 2023
City orTown A State •
, " �P .-,,, . ,--, .),----•..,.. 2I In*;
E�:-
CONTACT PERSON 0 o , 1.11 c ��`� c;���.�ti:
• MAIUNEADD /6, S D /� o/�e-5 ke e- .
IA a if: � �R f'1 C. .2 7z)2 12. :
70 QV orTown State Zp Code . -
(iiiiP 1- 22.8 /s- zz .
Area code-Phone number
s.WELL DETAILS: 5A HEREBY CERTIFY IPMS con ANCE vmi
; CONSTRUCTION THIS
aa.TOTAL DEPTH: ,2 s RECORD HAS -ao
a. D E WW.L.RACES W L YESU NO% _ -/4-z
C.WATER LEVEL Below Top of Casing: Fr- SIGNATURE OF WELL CONTRACTOR DATE
(Use-4.-IfAbove Top of Casing) • (}��.//./9 �vrl. c4 1, -
PRINTED F PERSON CONSTRUCTINGTHEW2.L
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Submit the original to the Dbrialon of Viktor Quality vAlliln 30 days. Awn infoInisaliOD FWD FotmGW-1b
lea Moil Service lamer-Raleigh,ITC 271;99-1617 Phi No.(919)733-701S ext Seti. Rew.12107