GW1-2021-02768_Well Construction - GW1_20210805

{ , SIDT.IV'1'IAL WELL COxSTRi1CTIOx RECORD
North Camlma Departs:cmt ofEmnoumad andNdura1 Rom-Division of Watcr Quality
fi WELL CONTRACTOR CERTMCATION# L 6 y- --
1.WELL COIi MCTOR: d- TOP OF CASING IS� f Fr.Above land SUS'
+� S,�r . 7 'Ttp off�m�mod ether below land a dace may r quffe
a va dame in accordance vrMt 15A NCAC 2C.01I&
Well contractor{in lei}Nam
e. YIELD(gprn): METHOD OF TESL 2i r�0 b/"
��.. :I� t DEN :Type Arnouoi c.� S
WA cor d saw Name ,r
STREET ADDRESS I L S PILL,.0 ej *C- S� WATER ZONES(ftlh)=
� From / t To 14( From To
n C_ From 1 d To i V 1 FriTo
CrilyfxTbwn Skit Zips
(3+). q x7-- Vyz& From To From To
Amu code- Rom narrlber 7. CASING: Depth Dialwater ThicbmwMW Material
2,WELL INFORMAINW.
SfM WELL ID S ) From To Ft
WILL CONSTRUCt'tQM PERM l $'`/
To Et_
OTHERASSOCURTMPERMITOPapp } Frpm$. GROUT: Depth Maul Method
3.WELL USE(Cho*App�Banc)M�on6ori*U
RecoveryU From To Ft^
1(IWmW at N Othmu (fat e S is FrcaL_Tq FL_
DATE DRILLED 1.0 n n o+.I r- Fromm To Ft.
TBAE COOIPLL[l t) AMLi P[d1O 9. Ste: Depot Diarnew Slot Size male"
4.WELL LOCATUM 11 Fum To F# (n. In.
CI Y: ,�►�a i 5 o n COUNTY .�T D lees From To Ft in in
m 3-7o Z S Frum To R HL in.
(�tdertla.t�drrtl�. Srrtrei�ii+dorl.tst Na..P4tcet ZA(•�!
TOPOGRAPHY!LAND SETTING: Depth
SANDI�GRAVEL PAC&
0 Slope a ValAey© Flat,r PJd0e 0Other Sim Malarial
(die* 1—Fr'd°b04 , be -- .-To
LATITUDE ,�,, t miffs s or Eras To F<
_ LOMGnJD>; �10 01 D.3 . & 92 , in a awl r -
From To FL
Latitndellong'dude Smu=,)rGPS 11 Topogeaphic map 11 DRRIM LOG
(bcWw of wank mugbe shown an a USGS fto mp and Fmm To Formation Desm# ion
aged to Oft form rtnotusMGPS) n- /Db ix h /Ch al«'*-
�DD - oZGO trrc % fit
S.FACiLIIti'-team natteMmebvtmeireiesiaareG _�FACR.1T11lD##fappftaW,
NAME OF FACT M
STREECADDRESS
�crratlon��
CdyarToHm State 74Pcode -p1jyK-3e'sG teK►
CONTACT PERSON .�A.
MAILING ADDRESS /,&4 gdke5d" ed, P�-
r, . 12r, J-7L5 Z 5- REMARKS: -
CfgtrnTown State TAP code �eeDer /0P,fo ,2oc, P a 0u^� IQjO
Area coda- Phone number
S.WELL DETAAS: IooMMErYCM*YTNATTMWEI.LWASr:ONsrrsuc WRIACCOlaMNMvrrrel
+ 15ANCAC2GW6tco"sTRwnQNSTN .ANDIMTAtQPYtiFTHS
a. TOTAL DEPM- J- 0 0 PROVIDEDTOPEVAILOWNEFt
IL DOES WELL REPLACE t7 T046,WELL? YESU N0)9 l `3 0
r~ WATER LEVEL.Below Top of CesMF_�FT SIGMATURE WELLCONTRACTOR [LATE
(U317t'+'ifi Above Tap of( ," - S/, ,
PRINTED NANIEJDF PERSON CONSTRUC M THE WELL
-SkIb l t Do 000nd to,do Din idan of Yalu Quaft w tM 30 daffy& Attic b tiOnuaijoo muL, Fern GYV-lb
1617 tO Servk e — ,NC Z7OW1617 Phone N L(91s)733-70ts ext M&
Rev.12M