HomeMy WebLinkAboutGW1--04618_Well Construction - GW1_20240809 . . Ill . : '
w F WEN7'IL Wzia.corisenorciutcoRD
Now Canis Depe tweet of Erwin:emit and Naiorai-i mourcea-Division of Wrier Quality
WELL CONTRACTOR CSIi�T!<FICATIOW;p f1 -A
.
- -_'I WELL counitecTow . • - L DISINFECT1014:Tine Amoral 2-- file. -
ease DT0Ing,and Pomp Services il.C. • sp. WATER ZONE;(depth): .
. Witi Corteges fridIrkk 1• �.
l�oroe >F�� To ISJr,:C
RaeTo -
i► ft CT Sage . - ROM To - From To
Wet CrmN eclair .'trtlp.W Name FromTO _ From •TO
. STREET ADORESS 204 Tom Ave - 7. /ie TlidNesei - -
- Caste-i Jayne NC _ 28429 _ From 0 �TTo 66 Ft. DiVilmr, WC. �tiM 4Q 1
(*Tiara Zip code From ToR .
(910 _231.6609- From 0 : To .' 0 F 6 ..a�. lit cited -SCh 40
Ass Dods- Phone number -
11.GROUT: Depth / taii iwi � Me rad.2,wBt OR TIM- - From 0 To 6� Ft, Eiel-Vot , C -;,p5 $4SEtYEIL D#
F4om To Ft -
wat.CONSTTM1 OIXIN PERMfW#oswQ.\JJP-Q4-r)dI Li' From, To . ' tat - - .-
- OTHER ASSOCIATED - o.p.r Dismsler Slot etas
3.WELL USE (Che ' emO Reek10111014 Weser Sappy 1 .— -Frml bti To kr Ft. 1. is 0%C) h,
DATE:DRElED 2 From _ 10 F4._„. it
TaiECQrwt.ETED AMI pMI - • Frerr__To FL _M. in. .
&S ELL LOCATMDIt - - . 10.aAND/6RAVEL PACK:
dry-_ff//Cfh''S-+-i-€//- ram�'o, s-114,1/�e(_QQOoffl1NTY- A e�vn�GpC-Cl.1,'I Tier F De441 To R. Sine _ -Materiel - _ -
`-�1` Ct-4 »C CSe--J+ .«O L - From To F L .-.
- (Steeitheie.timbers.Ccneodb.Subdt don.1.01 by Cam) Fran To Ft,,, -
•
TOPOORAPNIC/la1ND SET 1ING: _
Ships I Valley 1 Fit I Moe I Other
•• t .P..4,Aeiabob) 11.DRLLING LOG
tATiTi1DE .iei.depees, . From To - Formation DescaieGon -
.,_.,.— missies,mask or
LONGITUDE w adqusMl Eames — ZO {'-1- • CTGL
• '- • Lalitadp Ioogibidc solavc I GPS I Topographic map' _ /i /a\�
poaSon of well mot be shown on a USES tope map and x 6 - 5'O r t -I;,•vlo S--1rv\
aiachedb this font)i bat uo dng GPS)
E r191 OWNER :5 0 - 554 tvi LA r c7j_.1�
- NAME. C og_\e5 -SR e_ q,-/®® + . . .t-id,-
- M N]DRESS 4 o LI- .. 0 Qfk.. r 4-\e Hai - (Aa - - .
.--—Ob-. • . 1.3. RKMARKS:
a FELL DETAIL&
a. TOTAL DEPTH: ,l Oa -
•b DOE$.WEl.I.REPLACE Eornme aL7 1101 rmlERESY CERTIFY Tw►T THIS mums oOeenaCTIMNACOORDAICE.IRe1
G NFAT9YLEVFJ.11e&wT of ISIIICAC=ORE CONS7RUCSOMSTNIIARDS.AND THAT A01P'rMTH*
/ Top C l FT. RECORD NM Mal PnoN�m71Ew�1 -
(lMe'+`ifAbove►TapoFCs p)
d. TOP OF CASINGS r „VT Ft.Above sand Surface* \ . ,
•
- - -'Top of esii j ierrebteied aYbrbbbw lend adrteee men require TORE OF C WELLFONiRACTOR - DATE
at lenience in h000rdroe with 15A NCAC 20.0118.
e.YFB.D4gpek 5() I m o or Tuff LA••( ( if' PRINTED NAME OF PERSON CONSTRUCTING T 111 1C
'Submit the otiginot to the Division of Watok-Quollty within 30 days. Attn: madon Mgt, - -
1`17 Y1i09ervice Center-=-1oloh.IMC 2709-*IT Phone No.4919)733-T6#o eau t --