GW1-2022-06014_Well Construction - GW1_20220621

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_____RESIDENHAI,WELL CONSTRUCTION RECORD
.S : p' North CaroliziaDepadmentofFaavi><o t and Normal Rescuuces-Divislear®f Water Quality
.. `4ra---' WELL CONTRACTOR CERTIFICATION# a-6 irg.i i
1-WELL CONTRAteTDlt d.TOP OF CASING IS ' / FT.Abate Land Surface* .
. Jk.- , , , j >6A 'Top of �surboe
Well Canlr r � `p! " a variance in accordance 15A NCAC 2C.0118.
e.YIELD(sly): 10 METHOD OF TESTA,-Pole y
Wed parry Name f. DISINFECTION:Tyre �771 Amount 2-C.c--/5
STREET ADDRESS az... P'a-la-L4 e.f £4 g. WATER ZONES(depth):
/�+� �?a�L.� Rom To From • To
Mori-own State Zip Code From To To
.�lo_}. 113•-7— t/�/Z From To From To
(3
Area code- Phone number 7. CASING: Depth Diameter Thicurerawerglit Material
2.WELL
SITE WE ) - From 0 To $S'Ft. y.r Sc.k 'Id p/.5 6-&
WELL CONSTRUCTION PERMIT:iv 2�b' . RFrom To Ft
OTHER ASSOCIATED PEPI applicable) Fturn To FL
3.WELL USE(ChedcAppGcahIa Bea) !] 1Per5Fc 3 0- GRIM: Depth Material n Mettmd
IIlde From�_To FL �i-�,r1' ,��rc
�� otteertt ��) D hid a Frorq To R. San d
DATE DRILLED 19+Cv q From To _FL
TOILE COMPLETED AM] M 9.. SCREEN: Depth Diameter Slot Sim Malarial
4.WELL
CITY:LOC-step eer.S cecc ie COUNTY /e O e :,.Sr Rom To in. tn.
�f?�1�L,G�KK/liSlloro /� �.3 c! �ri/�, . Rom To,_ 4 . In.
s 7 From To in. tn.
(west man WO/a.Paree1 rto...)
TOPOGRAPHIC f LAND SETTING: - 10 SANDIGRAVEL PACK:
-jrS.tape U valley I] Flat U Ridge I] Other Size Material
(ctiocicapplopliaie box) Fo T o
MaY be in&item.
To
o
!LATITUDE /� y. 4 7/ ' s or From or
LONGITUDE !)o /e c9/.Sa2.3 I madx�al fort From To FL
. �tudellongiludesour�, 'GPS U Topographiemap 'i-D CLOG
(lacafion Owl/must be shown an a USGS lope tap and
From To Formation Description
attached to tbisfom'r fnatusing GPS) l�cl �SY rani{�/ 5 fi,.qQ i�t.I.'
5.FACILITY-in meRamed the business Were the mil islocsred.
FACIUDir ID
NAME OF FFACILrlv$PP �) _ t._' -f :.;:.-h'.it'; P-
STREETADDRESS _ I U N 2 1 n2
CityarTdrrnrrt State - p Code r;}.ri':? i; i 1—
CONTACT 4 il;,'•]F�{':e•f t f:': fi:j I
PAN )AOmas To y c' .
MAILING ADDRESS o2 D -5 S 1 p.5 an E g.e
d/L23 de,l'P Ti �- ,273S7 -
City or Town State Ty Code 12.REMARKS:.
( �31� )- yam? - N��3 �,-�•.€d We // •Ah�_e 11f) CciJr,— eexs:As
Area code- Phone number r a. s i s j i9 ci 'f'-'
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6.wEl.LDEfAILS: WOr YCIEFMFYTHATTHISWELLWAS ENACCORDANCE INREr
a. TOTAL DEPTH: / �/ iSAFICAC2C.WEIL CONSTRUCTION Sr'AMIIAI AND THATACCFYOFTHIS
DOESREM:03 �S PROVIIIEDTOTHE WELL OWNERb.
BeTop of l�SStg: _3 t7 FT_ NATURE OF 7It=!£D WELL CONTRACTOR DATE
( +-IfrAbave Top of Cssirlg)
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PRINTED NIANIEi )F PERSON CONSTRUCTING THE WELL
Submit the original to the DiViSiCIn of Viktor Quality within 38 days.
m G119-1b
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