GW1-2022-09931_Well Construction - GW1_20221031

RESIDENTIAL WELL 0NSTR1iIGTION RECORD
North Carolina Deparmus t of Eavkonmeat and Natural Resources-Division of Water Qaa(ity r
WELL CON TRACTOR CERTIFICATION# 4T'lii-A ±r;
1 WELL CONTRACTOR: f. DISINFECTION:Type Anwunt
Saga;DriflhrM and Pump Sir*m LLC. g, WATER ZONES(depth)
WeA Comretdor Name -To.-66 From To -
Michael C.Sa9e From -60 To_1 W From To
Well Contractor Company Name From To From To
STREET ADDRESS 204 Tom Ave 7. CASMG: Thickness/
. - Depifi Weigh -
Casde.Hayne NC 28429 From Toque Ft
C8yOFTown. State Zip Code From_fL-To1 Fes,_ -S6611¢
91( 0 . ,231-6669 Frar!__ _Tc Ft,_
Area code- Phone number
WELL INFORMATION:
8. QRDUT.' Depth l �Aeahad. ;
2. L� °
From 0 Tdog-Ft Ch 0 f
SITE V11Et1IDS(dappflcable) n Fror To Ft ✓Dwf ,
WELL CONSTRUCTION PERMIT#k C 6W W P'"Z�-O From_�To ! FL .►
OTHER ASSOCIATED PERMIT#(iF epPticabie) 8. SCREEN: Depth Die nab Slot Sipe Material
3.WELL USE(Check AppUCabie Box): Resido"Water Supply P. -From -.A To a,.Q7 Ft.A_in. in.. Ad
DATE DRILLED �" _ a. ront~?� F _� Ft,_ir, in.
TIME COMPLETED ° AM A pM®)- Fmm To R er. ix
4.WELL LOCATION: `� 1M SANDIGRAVEL PACK: S'
cmc Cas-f r
i e. HQ_vv- � w�
- COUNTY oaptt►:
FronL-70 FC 4C T 3 .1* 9912
(Street Name.Numbers,Conuraaity.S dMrdl�a'an.Lck No..Pared,Zip ) From Ta FL_
_
TOPOGRAPHIC 1 LAND SETTING: Pr-c:5G%i-4 Uh
a Sloe I Vary 1 Flat 1 Ridge i Other G'.alQ/23`JO
(che&apprqxWe bo4 11.DRILLING LOG
LATITUDE May be in deVm. From To Formation Descrippon
mimrtes,seconds or
LONGITUDE__ _ in a decimal format O-
Latitadalloagitude source. 1 OPS . I Topographic map Icil-
(location of weA must be shown on a USGS topo map and -
att ched to fhis form if not using GPS)
5. n WELL OWNER - \a
n �
OWNER'S WME is I�C711 �, lJ 011 C�-1� 5Q n
S'REET ADDRESS 3 Pet A hGa C
jC It'_ �Ni?- nc_� gyZq
City or T� State Zip Code .
di& - 2 5L Z
Arm Phone qumber 12, REMARKS:
$.WELL DETAILS:
a. TOTAL DEPTH: 00
b. DOES WELL REPLACE EXISTING Wt=LL.7 YE51 10 1m TmTTm WELLwAs mAcowavu:Evwm
15ANCAC2c. THATACOPYOFTt9S
l a. WATER LEVEL Below Top of Casing- FT. RECOa NAs To Na]ARD8
! (Use'+'if Above Top of Casing) ! «
d. TOP OF CASINGrIS FT_Above Land Surface'
`Top of casing terminated aUorbelow land surface may require SIGNAIVRE OF CERTIFED WELL CONTRACTOR DATE
e variance in bwordanoe wfth 15A NCAC 2C.0118.
- Michael C.Sage '
e. YIELD{gpm): �L S-' METHOD OF TEST (L lilt � PRINTED NAME OF PERSON CONSTRUCTING THE WELL f
Submit the original to the Division of Water Quality within 30 days. Attn:IMorntaBon Mgt.,
1617 Mall Service Center-Ralei(ih.INC 27SW1817 Phone No.t918i 733-701eo e=