GW1-2023-02440_Well Construction - GW1_20230404

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'R ENTIAT-WELL CONSTRUCfON RECORD
Apit Division roY�lflaterQu�ty
�1'.. 1;- WELL.CONTRACIORCERTIFICATION# �.6 y
I.MU.CONTRACTOTh d_lOP OF CASING IS I F/ Fr_Above Land Surface* •
I- // / 'Top afe�ng d War balm land sndface may require
.?tt re. �i„ :/1 i �Jri ;1 h a valance in accordance wait ISA NCAC 2C 0118. /�
Well Contractor(Individual)Kairte e.MELD(gr>): (9 ' METHOD OP TEST A i N Kp�af y
on e" LL.),, t�t c _ one. f. D�� Ir DISINFECTION: /7 7 a-H Amount e Alas
Well c
STREET ADDRESS cab a-n-u Z I x a WATER ZONES(depth):
From To From - To
• y 0 la.m. 1 L .7_7 UA-7 From To Fran To
Cdy6rTown Sbite TspCode From To From To
( r ea co.j- Phone J number��Z C ' - 7 CASING: Depth Dia m TlisknessMelatt tonal
2.WELL U REW7iDll: ROM 1) To X) 1 Ft____921 sc k -v2 S it
SSE WELL ID Ica appriedte) - From To Ft.
WEST CONSTRUCTION P 1fW a13 0 J !$ From • To
OTHER ASSOCIATED PERM1Ttz(ifappacabie) . 8. GMT:
3.WELL.USE((2 cAppicable Lox) ® �� p �J
Material
IndustrialCorturrembinAWI From b To Ft I-P Mil ti� Pea re
Inigatiol0 OtheiD gist use) / D l b re" From To Ft. Srr 1.et z
DATE DRILLED /9 0 From To FL
TIME COMPLETED • AMO MO 9. SCREEN: Depth D-rameler StotSme Material
Q.tIll T_LOCATION: j Eton; To tn. In.
CITY- .J4 oXes �a l e a�UNnr c�/C�n t AP From To In. In.
117 Ikr .sIN 14 o2 7 3 S7 From To Ft in. in.
• (SIMI Nemec.Numbers.Community.iy.Subdidsian_Lot ND.Robot EPCcde) IS.SAt@1GRMIEL PAS:DepthPOGRAPI UC l LAND SETTIt D Sine Malarial
'Scope DI Valley 17 Flat 0Midge Li Other Eton To Ft
(d MaY be in cicifees.
LATITUDE • ,s or From To
ina decimal farmat From To FL
LONGITUDE - -
• I e/1ongilude sourco S 13 Topographic map 11From NG LOG To Formation Description
(location off mustbe shown on a USGSBono ivap and —. __-- -
•affached(afhrisfarmffnotrrang '" ''
S_FACIIm rs en name come businesswere mown is imam_ APR %) is 7073 -
FAMILY IDa(ifeppti able) --
NtAMEOFFACILlTY /� � - - i(1�Gi:�� �'�1Pr�"��((-•':rg (�.i
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• STREET ADDRESS {Y/
City orTown State ' nZ - •
CONTACT PERSON. hi a•r-V e 7 1- i d u le--
• MAILING ADDRESS l// -rk r u c 1 j 1
S+oT y5 Ga•/t State t rip-7.ode�7 12.REMAR)G •S
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Oily orc i" e,e cJ c It ro�� • 8/
( 3Sidi- a10 •- b1y(i - 11isIt1, pipe. I)w .2. 10 RuS4 U'fr
Area code-Phone number a _1 - J-,
6.WELL DETAILS: toe HEREBY cemFYINATUSWE3.LwascorSnwcrEDev WITH W
DO , ws.L RECORD PROVIDED-ID uv�.Lsr ra aTHATArxlProMOS
a.TOTAL DEPTH: ,
It. DOES WELL REPLACE WISTINGWELL? YESCU NOV ej /2-3
C.WATER LEVEL Belgar Top ofCasing: l_'0( FL - 1OF Wl3 L/CONOTZACT�d DATE
(Use+iAbove Top ofCasing) - ll , �yi :4 ti -
PI NANOF PERSON CONSTRUCTING THE WELL
Submit the original to the Db i ton of Water QtiaUty within 30 day& Attn:Infernielien Mgt' Form sGW-lb
1617 Mail Service tattler—Raleigh,NC 27699-1617 Phone No.019)733-7015 act 668. Rer.12►07
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