GW1-2022-03683_Well Construction - GW1_20220321

RESIDENTIAL WELL CON97RU iON RECORD
North'Catolina Department of htnvironment and Nagar Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 4119-A
WELL CONTRACTOR: _
f. DISINFECTION:Type Amountjr
Sage Drilling and Pump Services LLC.
g. WATER ZONES(depth):i
Well Contractor(Individual)Name From< To From _To.
Michael C.Sage From ,__To From_ _To
Well Contractor Company Name From To From To
STREET ADDRESS 204 Tom Ave 7. CASING:
Thickness/
Castle-Hayne NC 28429 �D Diameter Weight 1
City or Town State Zip Code Fr I % Ft_(. jD,From -.-
To Ft,
91( 0 }231-6669' From To. Ft
Area code- Phone number
2.WELL INFORMATION: 8. GROUT: Depth Material Method
SITE WELL ID#(if.applceble) From To Ft» D(a�
From To-
WELL CONSTRUCTION PERMIT# A,) ao.I[N From To Pt
OTHER ASSOCIATED PERMIT#(if apprrcable)
9. SCREEN: Depth Diameter- Slot Size Material
3.WELL USE(Check Applicable Sox): 'residential WAer Supply 0 From ToL Ft in. In.
DATE DRILLED From To � Ft,_in, in.
-------------
TIME COMPLETED AM 0 / I�4,11 Fmrr To Ft„_in, in.
4.WELL LOC47AON. 10.SANDIGRAVEL PACK:
Cam Q: COUNTY Depth Size Material
From- To Ft `
From To FL
(Street Name,9Vumbefs,Community.Subdivision.Lot No..Parcel,Zip Code)
'From To Ft.
TOPOGRAPHIC NG:
0 Slope 6 Valle 0 Flat Ridge 0 Other
(area: ate box) 11.DRILLING LOG MAR 1 202?
May be in degrees; From to Formation Description
LATITUDE r i minutes.sebonds or _
LONGITUDE_ in a decimal format _ I :;.'�ti'`,,
Latitude/longitude source: I GPS 0 Topographic map '- 2, T �M
(locatign of well must be shown on a USGS topo map and
attached to this form ff not using GPS) q
L WELL OWNER
ell
OWNER'S NAME `
STREETADDRESS
z. dQe
f /lily orTowq�n State Zip Code
Area code- Phone ryumber 12, REMARKS:
e6.WELL DETAILS:
"t a. TOTAL DEPTH:
b. DOES WELL REPLACE,EXISTING.WELL? YES I NOB I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WRH
15A NCAC 2C.WELL UCnON STANDARDS.AND THAT A OCPY OF THIS
/ c. WATER LEVEL Below Top of Casing: � Ff, RECORD HAS BETTO THE WELL OWNER.
(Use"+'If Above.Top of Casing)
d. TOP OF CASING'IS _FT:Above Land Surface*
'Top of casing terminated aVbr below land adrface may require SIGN RE OF CERTIFIED WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. Michael C.Sage
e. YIELD{gpm): Y ll J METHOD OF TEST bit •I PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the oiriginal to the Division of Water Quality,.within'30 flays: Attn:Information Mgt., Form Gw 1$
1617 Mail Service Center-Raleigh,NC 27699-1ii77 PW6ne No.(919)733-701S extS68. Rev.3W
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