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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 --