GW1--07279_Well Construction - GW1_20231109

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_ RESIDEN'IAL WELL CONSTRUCTION RECORD
f North Carolina toiEna
a�� and Natural Resources-Division oflWaterQueriity
• ' WELL CONTRACIORCERTWLCATION# a6
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i.WELLCONTRACTplt d./ TOP OF CASING IS 19 ' FT Above land&dale .
. -Tbk.a. Ph :11i Sip, ;IA "Top°Teasing terminated atlor below Land surface may,require
Well Contractor(burl al)Name
a varimtce in scoot wMr 15A MAC 2C.0118.
15$4,. i:i/,• �:,•..eik 1.J i1 c.o. �.tc. ( k I ltINTT1ODOFTEST it OJt
'+ Contractor eftny cane E DISINFECTION:Ty+I f/7N Amount 2-e yo
STREErADDRE S yaks 7 a.tc e I 41,e - g. WATER ZONES(depth: '
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C.cz f �. 'I �70 ..7
fri From To rirt • To
Cfty&�t ITown State trp{;ode Fmm To To
(336). Y.2.7— tl y2 Lp Rom To ' From To
Area code-.Phone numberT. G: I '
2 WELL INFORMATION: Material
sffEWEl.1.tDj - From To Ft �� Sc
. NELLCOAISmRUCfnNPI uursoli ap�6te1 PJ.36$k-(/1s From To : Ft
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OTHER ASSOCIATED PERMITAK ) • From To F2
3' ttf ustri ��) O Muuic paUPub�p-- - —&-GROW= � Matdal - Method
madlyi 0 Main (list use OM-t S ft- Froth © To 7' Ft
DATE DRILLED i q 2— • _ From To Ft, s
From To „ Ft -
TIME COMPLETED AMO PIM 9.SCREEN: Depth Diameter got See M
atedel
4.WELL LOCATION:M e r. 'Pi '/
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CITY: .St.hi C�® COUNTY/`D c Ki a_An eon, To �! L In. .
-05 /ah C or C
�, 1./� From To in.
(Sh�eelt�l8rae.l+bmpa� 9ibliuman.tatNo.P431ipe1.aP(�p�i From To `,FFL 61.
CI LAND SET fING W.SANINGRAVE.PACK
Sto
,P=Halley a fret 0 RidgeEl Other
- • Siae Material
(chodcappmpairabm)
� / G , Enerm_Ta
LATITUDE J a ro b,s, "I 6 JI hfaY he in or From Too `FL
LONGRUDE ijo_22 °S I, 0.2_0' ina decimal gmaat From To i_FL
. Latitude/longitudesour=%C$S 0 Topogtapbicmap 11.ORIWNGLOG I
• t ►eweumustbes nonaUssstapoinawa and
From To Fan nD
anadiedia fatmf not using GpSJ -
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5.FACRITY-I3 the.e.eQdumaxisnessyreee aware isIm o. _ _,
FACWIYIDR(ifappr ble) I >' 1 vgf'_..,
NAME OF FACILITY • - i.
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SIREETADDRESS i NOV 2Q23
r. ,r)
City orTowir n• State Tip Code {n ' ;c'. -
CONTACT PERSON K C.A. ,,a,/I C ) Y. . . .
' MAILING ADDRESS .2.D.S G-/e, G o e. e.n. L o0/4 • l
-5ah"►n, rr f T.Le, 4c.
• ,IS to
or Town rip Code 12 REMARKS: I/+ •
A8Jam! //3V - 0 A'�e l RS ih'Q [Jut o ISu-s`]�
Phone number
S.WELL DETAILS: s rood rarmFYlwcrTIiSwe iWAScO tstr etrAcoot wmr
7.a.TOTAL DEFILE: a? .15a � +-OAST . D'ntrsTACor=ttOFTtrts
RECORD HAS •-. n Ta WO.L( 1VN8.
It. DOES WELLREPLACE EX1STIN aWELL? PESO /' /� . /d/9-2-3
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a.WATER LEVEL Below Top of Casing: oL 8 r Ft. SIGMA ) OF +❑,WET.L CONTRACTOR DATE
(Use'+If Above TopofCasinfd - fj �l; 1 44 -
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PRINTED OF PERSON CONSTRUCTING THE WELL
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Submit the original to the Division of Vaster Quality within 30 dam Attu:Information 10.i'
1617 MB Service Cettir—Raleigh,NCg7698-t6i7 Phone No.(91g)735-7016 ext&68. Form�1b