GW1-2022-09932_Well Construction - GW1_20221031

µRESIDENTUL�ixm CONs utnON RECORD
North Carolina Dep=M of Environment and Natural Reaoiiroes-Dimlon of Walm Quality
WELL,CONrRACTOR CERTMCATION# T1
1.WELt.CONTRACTOR: f. DISINFECTION:Type Amount tb
Sao Drilling and Pump Services LLC. g, wAirlEft ZONES(depth):
Well Coneaktor(Individual}Name From t Q To From � To -
Michael C.Sage Fran To From To
Well Contractor Company Name From To Flan 70
STREET ADDRESS 224 Tort!Ave 7. CASING: Thidgaressl
'Toll
r Wetht c
Castle.Hayne NC 28429 ;. Fra C) pT n - o[,Yti Ft�. •(h Nr) -
City of Town State Zip Cade From .R To Ft,
;9'!� 0 �,231-ti669 Fran To Fs
Atria code- Phone number
2.WELL INFORMATION: 8. GROUT: Depth Malm." Mdtrod.
From 6 To !F i Q�ftS/'11 elAt ✓'
SITE WELL ID P(rrapp ftW) 1 Fmm�To �Ft
WELL CONSTRUCTION PERMrr S W Sul Z Z r bl I- From To P
OTHER ASSOCIATED PERMnnit appkMe) 9. SCREEN: Depth Diameter Slot Size Matte
3.WELL USE(Check Applicable Box): Residential WaW Supply 0. From To . Ft 0. In.,-DATE DRILLED G 11611 7 Z- From_To Ft.—In.. In._
TIME COMPLETED_ t � AMR C From _To Flan ta.
-G WELL LOCATION: 10.SANDIGRAVEL PACK: ° "^-- L iV
� Depth Size -Maw
CITY: l 1 �I`ld�0� COUNTY�II h(.tY�VC Fmk- To FtOFT -1
From To ��----�--
(Stied Nerm NwrOm.Cormnwmy,swo"m Lot m.P rrccd.av Code)
TOPOGRAPHIC/LAND SET71NG:
Slope a Valley I Flat I Ridge I Ofher 11.DRILLING LOG
(cfmckAWWWe°000. Iviay be in 4egas, FTn JO Q F rmation Description
LATITUDE minutes.seconds or
LONGITUDE__ -- in a decirnal format
Latitade/longitWe-source: I GPS I Topographic map, i
pocatiort of well must be shown on a USGS topo map and 2 •—
altarhed to this form if notusing GPS) VC
8.WELL OWNER D V .,
OWNER'S NAME f jn��t•&lc
MIZEETADDRESS i' 2 �L .g CA he-±_F KD
1a %-Iml hC ?. Flo
uy or T State Zip Cad§
Area�colle- Phone rpimber 12. REMARKS,:
4,L WELL DETAILS: - --
a. TOTAL DEPTH: �2S
k DOES WELL REPLACE DUSTING Wp1.4 YE I NO I r DO TMT THM y�WAS W M ACCo wmk
r /sA NCAC 2C.we1 C0WMUcnOM sraND11N0 . 7W►T a ooPr oFn�s
c. WATER LEVEL Be)oidTop of Cashrg: FT; tktcaRnw�s
(Use­1*"ff Above Top of Casfig) �
d.TOP OF ftea ft'.IS ml FT:Above Land Surface' SIC, R1 OF Fl WELL CONTRACTOR DATE
- 'Top of�cadiing lemrinated at/orbelow land sdiface may require .
s_varWiga inracoardance wfth 15A NCAC 2D.011a. , Michael C.Sage
e. YIELD{gpn*. 50• METHOD OF TEST l �� PRINTED,NAME OF PERSON CONSTRUCTING THE WELT.
�
SUbMifth@ tliriginal to the DivisibR-Of Water-'Qtmuty within 30 hays. Attu:InformationI Mgt_ Fam QW-1a
1617 MaN�rvice Center—Raletgh,He 2769*167 'hone No.[phone]'ext S11111 j Rom;