GW1--00206_Well Construction - GW1_20231229

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NLyyYY}} 0f , t.. NON RESIDENTIAL WELL CONSTRUCTION RECORD
1 ( •• / North Carolina Department of Environment and Natural Resources-Division oflWater Quality
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WELL CONTRACTOR CERTIFICATION# 5e 7 IA1
1.WELL CONTRACTOR: -d, TOP OP CASING IS 75 FT.Above Land Surface'
t ' i" j 'Top of casing terminated at/or below land surface may require
•WallSontractor(Individ Name - a variance In accordance with 15A NCAC 2C``.0118. J
--J' r'rut ckLC_ LA014-4 A.J ;G 44-C e. YIELD(gpm): /IC) METHOD OF TEST,p g c•.) Claw y`
Well Contractor Company Name
3s--A i'V o(.f ( e-e, -) A f. DISINFECTION:Type /1,(4'fr'( Amount X
Street Address, g. WATER ZONES(depth):
.4 .0 L.C.L.C. r 5 6 i+:,z9 ,_-1(.(-.. Top iv, Botlorr/6 C-P4 rop Bottom
City or Town Stag . Zip Code
Top Bottom Top Bottom
(Cf//p) ' 9'/ • 9 / L Top Bottom Top Bottom
Area code Phone number
Thickness/
2.WELL INFORMATION: 7. CASING: Depth - Diameter Weight Ppterlal
WELL CONSTRUCTION PERMIT* /1/0 rY p Top" `f Bottom I& Ft. 6 5,6A
OTHER ASSOCIATED PERMIT#(if applicable) Top . Bottom - Ft.__
SITE WELL ID*Of applicable) Top Bottom Ft
3.WELL USE(Check One Box)Monitoring❑ Municipal/Public❑ 8. GROUT: Depth Material Method
Industrial/Commercial 0 Agricultural if Recovery❑ Injection❑ Top V Bottom 2q)Ft v+0✓Z7;;;,r iii 0000 Lir to
Irrigation❑ Other G (list use) Top Bottom Ft.
DATE DRILLED I'/- a ` g, --Top Bottom Ft.
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4.WELL LOCATION: / ,/ S. SCREEN: Depth Diameter Slot Size Material
- 45'-/ / 94 /f Lrf L') GI)• , Top Bottom /Ft. in. in.
(Street Name,Numbers,Community,Subdivision,Lot-N6.,Parcel,- Zip Code) Top Bottom Ft. in. in,
CITY: � :-,n $r.1 f&Co) COUNTY�t-GL 4.6 irk Top Bottom / Lin. in.
TOPOGRAPHIC-7 LAND SETTING: (check appropriate box)
0 Slope ❑ValleyAla( 0 Ridge 0 Other 10.SANDlt3RAVEL PACK:
c! - Depth Size Material
LATITUDE 36 "-oo3�' 77/ "DMS OR 3X.XXXXXXXXX DD Top Bottom yt. •
LONGITUDE 75PW=-.ct' �!'6q`"DMS OR 7x.xxxxxxxxx DD Top Bottom t.Latitude/longiiude source: BPS DTopogrephic map Top Bottom t.
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) 11. DRILLING LOG '
5.FACILITY(Name of the business where the well is located.) Top Bottom' Formation Description ,
Facility Name • Facility ID#(if applicable) I a�� ,y / a = Z # _
Street A ddress / iC Gc (
/
City or Town State Zip Code / _
Contact Name /.
7g.�' r NC 9'6 // le-)' � / nvr 9, q 7r19a .
Mailing Address / _
E/o a.r2 I S tl r�4�.1,.e , A/ .. -- / inforiy;;E:fl nrcz gl Ut•;
CitytirTown State Zip Code D:C C.)4:3
12.REMARKS:
Area code Phone number ,
6.WELL DETAILS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE+ACTH
;'� i 15A NCAC 2C ' -IL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
a. TOTAL DEPTH: 0..i RECOR► BEEN PROVIDED TO TH LL/o�NpSz.
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO „ '" ,��' !��' // 2 ^02.�
nn , S'• ;%URA CL TtFIED WELL CONTRAC-TOR DATE
c. WATER LEVEL Below Top of Casing:- raZ:a FT. c`,} 6,r f 6, L-L-
(Use"+"if Above Top of Casing) PRINTED NAME OF PffRSON CONSTRUCTING THE WELL
stiitnc Form GW-lb
Submit the anginal to th-e Dieleidlt of W tet'QDti lie thirl30 ddjois,A Infetrnatloh M ,; Rev.1 vos :
1617 Mall Service Center v Raleigh,NC 27699-1617 Phone No.(9* O7T4360 1