GW1-2022-03677_Well Construction - GW1_20220321

RESIDEM'M wELL coNSTRucnoN REcoRD
North Carolina Departtneat of l nAwnment and Natural Resogrces-Division of`Water Quality
WELL CONTRACTOR CERTIFICATION# 411"
1.WELL CONTRACTOR: L DISINFECTION:Type �"«1--� Amount
Sage Drilling and Pump Services LLC. 9, WATEtR�ZON (depth)'
Well Contractor pndividuaq Name From' ' 15 �0 Fmm Tb
Michael C.Sage From To From To
Well Contractor Company Nome From To From To
STREET ADDRESS 204 Tom Ave 7. CASING: Thickness/
�_ D mete` Weight I
Castle:Hayne NC 28429 From To_. Ft-
City or Town State Zip Code From To Ft_
91( 0 )-231-6669 From Tc Ft
Area code- Phone number
2.WELL INFORMATION: 8. GROUT: Depth QMaterial Method
From D To Ft�7PSeT-(�1" �C�1 t� 01.�!
SITE WELL 10#Cr►applicable) From_To-9n Ft y t- `�1 c7CAr �1 f
WELL CONSTRUCTION PERMIT# From To 1G t.
-
OTHER ASSOCIATED PERMIT#(if mplicame)
8. SCREEN'' Depth DlamAer SIO Size
S.WELL USE(Check Ap b ): Residential Water Supply 0 From T.oL gU Ft in. In..
DATE DRILLED From. To Ft._in, an.
TIME COMPLETED AMA PM I From- To Ft in. In.
4.WELL LOCATION: +1 1 10.SAND/GRAVEL PACK:
CITY: �, i� A��lz+� COUNTY IV 6194
T MCIVef Depth Size � n�+
33 5f ante To FL
OF" 9 0 Frmff To Ft�` 1
(Street Name,Numbers,Community,Subftsion,Lot No..Parcel,Zip Code) From 7 o FL M Q R5595
TOPOGRAPHIC/LAND SETTING:
Slope a Valley I Flat •I Ridge B Other
11.ORILt(NGLOO _
• (chadc appropriate box) ,
May be in degees; ,From To Forii►ation Description
LATITUDE ,_ minutes,seconds&
LONGITUDE__ in decimal format WZ A 0
Latitude/longitude source: I GPS a Topographic map c O 4hei MY
pocoWn of well thUst be shown on a USGS topo map and
attached to this 064 if not using GPS) tA'%
'b.WELL OWNER �
OWNER'S NAME _
STREE ADDRESS `off 3 3 _• N:Mba n M
} C �lM1ng-1an NC alg69 A-
City or Town State Zip Codde
i - SLla -5559
Area cotle- Phone riumber 12 REMARKS:
q&WELLDETAILS:
Y a. TOTAL DEPTH Cell
b.:DOES WELL REPLACE EXISTING WELL? YES I NO I 100 HERESY CERTIFY THAT 7HS WMt.WAS OONSrrrucreD IN ACCORDANCE WITH
isA NCAC 2C.WELL CONsmue 1oW STAN[WtDS.AND THAT A COPY OF THIS
c. WATERILEVEL Below Top of Casing: 16 FT. RECORD S THE WUL OWNEIL
(Wse'+'if Above Top of Casing)
d. TOPW CASING-IS. t' FT:Above Land Surface'
*TWO'ciWftii terminated aVor below land surface may require SIGNA R R D WELL CONTRACTOR DATE
a variance in bcooroance with 15A NCAC k.0ii 18. f Michael, Sage 1
e.,YIELD{9Prii}:_ )�V METHOD OF TEST//'1 t C i i�- PRINTED NAME OF PERSON CONSTRUCTING THE WELL
SubMit the:original to the Division of Wafer QuaI116 within 30 dAys. Attn:Infotmtion Mgt.,
1617 Mail Service Center—Raleigh,NC 276994617 Phohe No.(9191733-701 b e7a