GW1-2023-02436_Well Construction - GW1_20230404

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• DE :IV/14T_WELL CONSTRUCTION RECORD
4. : _V North Carolina and Natural Rom-Division oftrat Quality
. ,".. WELL CONTRACTORCERTIF'ICATION# 12-6 �S-
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,.iNB.L CONTRAC10Ib d.TOP OF CASING IS / Ft Abate Lend Surface* -
. -1k,,. PA :r1 s,�, ; 1 'Topoffangtad arbelar�rland stuface may requir+e
a variance in accordance 15A NCAC2C.0118.
IMO Contrar (tit} e.YIELD(mu): 6 D METHOD OF TEST 4 i,^/20'k t
0 QOr.` S;.Y fik LJe_T 1 C . ..7rKc. f. DISINF IOH:Tjipe d ! hAmount .-.C K/35
Wen Contractor O. ty Name
STREET ADDRESS ak.,. A. el Le S- WATER ZONES(depot):
From /03 To/5.4 From - To
• JO e--,1 0 di&h n L .1.7tx.7 • From To From To
My tir Town State Trp Code From To From To
( 36 r 3-7— Citt/2" 7 CASING: Depth D" Material
Atea coda- Phone number
2.WELL I NFORNIKRON: From D To .5 FL I'' so A=9 i2 PA S7LA
SITE WELL IDVappfiratie) - From To FL
WELL CONSTRUCTION P G/,�,'�30 3-ace/ Rom " To Fl:
OTHER ASSOCIATED PERMlT#ffupproable) 8. GROUT: Depth /� n Method
3.WELL USE(Check Amicable Box) ® LioniripaltP+D From D To it �,r FL Po r?l�li 4z� (!'C a Pc d
irrigationp OthaD (aSt use) 6 h't e S 71 f e. Frort�To - A
DATE DRILLED 19 (n R From To FL
TIME COMPLETED • Aral PMD 9. SCREEN: Depth Der StotSim Material
4.WELL LOCATION: Flom To FL � in.
CITY: ' S4oh e »life COUNIY/�p 0c�i�9 Aa»` From To FL in.
3 G q oe cjt-v tJ F, • ..2 7 o t/g From To FL in. In.
(Shed Nana.riumteas. Subdivision.Lot Ha,Parcel,ripCade) 10. RAVB.t?/t42rC:
TOPOGRAPHIC 0 LAND SEr IIG: Dept I
A Slain O Valley U Rat"Ridue U Other
CaedraoomorkilA box) ,�� B n To____417___.
MaIrLATiTUD>= . , -/, iiV/ minas.seconds er From To
LONGITUDE L Dal .$mil• 50 S"' in adxrmal format _FmUL.___To FL
• . Lalitude/long�de sor row/X( PS ® Topographic map 11FRml1N o LOG Formation Damon
after!
(tocagaacfwmustbe shot on e USGStopo map and /y/ - OP G r c_n I fC
.attached f a This form f not usbzg GPS)
8_FACILITY-Sera name ormeAefioesouiferetherorniswad. • -
FACILITY ID0ifapple) -,. _
NAME OF FACILITY ill A • : -
STREEi'ADDRESS ti
• APRvitND .
CkyorTown State Z+itCode •
,�1 i• t-i
CONTACTPERSON s4 ;Et_ �Eaa-At.5 :n;c; ^�-,. .- : .,-•,:-
mums ADDRESS 3 b y e✓D e•a r t w le,,
s /i<)10 h e i/i e. /I C a-7o i/e ,�, -
REMAR
C�orTown State At i//z ia°. lee pr r nor �o /i 1/lc `^�a+er
( � $�/ "7 ' 9 ��/ .3 I- 1I , ,it /Jue #o eashl rush
Area code- Phone number 3
6.WELL DETAILS: too test Y CERTIFY THAT TM WELLWAS CONSIRUMED94 ACCORIANCEWITH
e.'" 15ANCAC2C.WELL CONSTRUCTION STANDARDS.RIVDTHATACOFIf FMCS
TOTAL DEPTH: 0 t) R FRavmEDTOTttav,�t.a .
b. DOES WELL REPLACE=Su tra WELL? YE8D NO$t �'� • Z`I V-,.23
c.WATERLt 1.Beiraa►Trm ofCa FT_ SIGNA'l`U OF WELL CONTRACTOR DATE
(use�'IAbove Top ofC ) • ,i ; 4,t2 ; -( 1
PRINTED NAME(lF PERSON CONSTRUCTING THE WELL
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Bataan the original 10 the Minden Of%Valor Quality within 30 days, Attn:infonuation Mgt.. Form ia'VII4b
1617 Mall Service holier—Raleigh,NC 9-1617 Phone t io. 9)7337615 eat 6691 Ier i21D7
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