GW1-2022-03675_Well Construction - GW1_20220321

RESIDENTIAL W LL coNSTRLc ON=CoxD
North Carolina Dgm=M of Eavuonib t mad Na g RoDuivw Division of Wawa QaaHV
:c . 4119-A
WELL CONTRACTOR CERTi ATION# ..:
t.AIIELL CONTRACTOR: f. DISINFECTION:Tie I-IT4± -I Amomrt -
Sage D R!%and Pump Services LLC. g. WATER ZONES(depth):'
Well Contractor(Irmuiduai)Name From-90 To 1';0- Fr m - To -
Mic haei C.Sage From 1 To _a From To
Well Contractor Cornpa"y Name From To From To
STREET ADDRESS 204 Tom,Ave 7. CASING: Thkimesal
Castle-Rayne NC 28429 From k1 Two-I - Ft
Cdy of Town state Zip Code From , To
91( 0 .}231.6669 / Fromm To ISC Ft ' �/ h
Area code- Phone nurrnber
2 WELL INFORMATION: 8. GROUT- Depth Malaita! p Method
From_To F
SITE WELL ID#(i applcade) FrorrL_To Ft.
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WELL CONSTRUCTION PERMIT#05W 1'V1k - d�-OL�I Fro =3__To t Q
OTHER ASSOCIATED PERMCI#(d apptiea6le) 9. SCREEN: Dish Dier netet Slot Size Material
3.WELL USE(Check Applicoble Bob: Residential Water Supply 0 From To- -�7r Ft in. h.
DATE DRILLED_ Frarn= F—In• kL (��
TIME COMPLETED `6 i CO AM 0 PM® Frvrrn To_Ft an. ip
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
0 COUNTYuCW 1►aCwId Dom' Size MaRnat
CITY: `` From- To Ft r-c
GSQLQt T`10�r[ _7 _ i11��� �I Froaj_,_To Ft i�•; r. r;, : ;, E
reat Mn%Numbers.Corrmkoft.30d1wwm Lot No.Parcel.Zip(bde) From TD F�, ,�
TOPOGRAPHIC/LAND SETTING:
Slope a Valley I Flat 1 Ridge 1 Odw
(dwft b04 11.DRILLING LOG 7
May be in degrees. From To ormahba desrnppon ^t r J i
LATITUDE minutes,seconds or
LONGITUDE _ in a decim at
al Form
�.— 10L•
Latitaddlongitude sowow. N OPS . N Topographic map' -
(locado n of well must be shown on a USGS topo map and
affarhed to this form rTnot using GPS) —
- ®�— .� eXAse six 'X
L WELL OWNER
OWNERS NAME I 1) M i
SfRff-TADDRESs O
04Y drrown Zip Code
Arejk cade-Phone u, �:3Do t bS o-C OF 5�c-u art
B.WELL DETAILS: ' �� //
W TOTAL_DI MAILS:
y 4 15D_I" GCCx.lt�d C�5i R
�f� Mn-Ian,4e C ti f Tbla
b. DOES WELL REPLACE EXISTING WELL?ViS Vr NON Do HERESY cERT THATTHS WELL WAS ooNsr nww IrACOORDANCE WRnnt~ WATER LEVEL Below Top Of Casir�: 1sA NCAC 2r;� HEWaLCONsreuCrroH STANDARDS.ANDTMT AOOPYOFTM
"oFT. RECORD HAS TYYaLON 93L
(Use.•+•ff Above Top of Casing) I�.Q�
d. TOP OF CASING-ts FT.Above land SurtaW
'Top of casing tern dnated at/or below land stirtace may require S�NATUR OF C IR WELL CONTRACTOR GATE
a variance in bccordanoe with 15A NCAC 2C.0118. Michael C.Saf e
e. YIEI.04gprn} c:*--J METHOD OF TEST \ i � PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the ofiginal to the Division of Waiter 0wilty within 30 drys. Attn:Information Mgt.,
1617 Mal Service Center-RaNefah.-NC 27699-1017 Phone No.1919)733-7tr c ezz.=_,_- --__.