GW1-2023-02441_Well Construction - GW1_20230404

_ .RESIDENTIAL WELL CONSTRUCTION RECORD
3.2- �t North Carolma Department ofEnviramemtaadNaturral Resources-DivuionofW Quality
. WELL CONTRACTOR CERTIFICATIONS
1.WELL CONTRACTOR: d.TOP OF CASING IS f 1 FT.Above Land Surface' -
f� / 'Top of easing tin ed aderbe low land surface may require'
i?�1 r�. D" ./1 ��n . vti a variance in accordance v�115A NCAC 2C 0118. �J
Well C ntrachr( Co. • .YIELD(gran): 5'ea (METHOD OF TES �iripio j
<1.+1a'AH Nh:f�.-�J iv.:f4 t;+)t/1 C�S� v►Ga . DISINFECTION:Type 1/ /# Amount 2-a up
Well Contractor rfterm y Name
STREET ADDRESS a A nta -AALe-1 Le - 9- MAIER ZONES(de:pth):
Frain a To AV Rem - To
- y7]G60las% a L �7aa-7 From z?S To a-7(2 Fran To
Cdy Town State rip Code From To Rem To
• ( 3Area o.code-1. g.Phone
o e n 0Y 7 CASING: Depth Diameter Tim.Notarial
&WELLINFORMAIION: From D To n (a '18 $el�' /DIAsf
SUE WELL lDai spp k ) From To Ft.
WELL CONSTRUCTION PHtYiid{d ) Ell U P 3®/-003 From . To Ft
OTHER ASSOCWTEDPERMIT appil:able)
3.WELL USE(ChesicAp a Box)manunangu lzunicipaPubrica 8. °Rohl: DePth t n
MatanialMethod
i A� Recovery)] From 0 To )-D R.R. PO r.Tf( j I"0U ref
Inigalio*) WWI.pause o w.e S f'L F�-_-_To /'u 1 Pt d.S
DATE DRILLED 1- 7- ?- 3 � From To Ft
�
TIME COMPLETED aZ '"9D
'.D 0' AMn a� •
9.SCREEN: Depth Diam r Slot Size Material
• 4.WELL LOCATION: h•p /� Egan To in. In.
CITY ill /�i S 0, COUNTY 0+�o�;t Zc� From To FL In. in. -
J �l .t o: 017 025 Flom To Ft. in, in.
( e dNerne. cL P ian.totHa.Parer.TPCade) 10.SANDlGRAVEE.PACK:
- Depth O Slapee TOPOGRAPHIC Vall y,Flatt Ridge 0 )] Other To Malarial
• (thedceaxopriaortime) Free
/_ Ft
i Maybe m
LATITUDE 1�.2-/ o g%3 mader,seconds
ec ndsor From To Ft.
mniat From To FL
LONGITUDE�9. 8 t to 6
11.DRILLING LOG
LatitudelIongitude sourccx Q'S 0 Topographic map Ft m To n Description
&welmost shown oar a USGStapo rrmP and fJ' ee, `
•aBSdaedtoMiRfarmf not using•GPS) S. - w, A ro,,,t- Sw 5a..f Koc.0
tib — Zoo` 0ra.,a• to-
5.FACILITY-bibs nacreateesaoecsrteseffiewlisrowed_ -
fAYWT■ID RiT ap ) vw ..ys r..*..'
1 l l f
NAME OFFACi I Y A A • ,"`,. v. ,r ..s '�__ _.,
STREET ADDRESS A P R ti 14 .111'L3
CliyarTavm State 4oi;.:ii'; �1 r
:�r ..:y':. .'._J a,-
CONTACT PERSON .1-e l f C 0!e. • L.> :,,,,„:J 4
MAILING ADDRESS //c'1 t 1-n die.r tI_a k e .
M aA d i s c i ° yl C _7 C •2. 12.REMARtiS:
( y orTown State Tip Code -
( 3U0 ).. (9e 9 - /6 3 o -
Area code- Phone member
6.WELL DETAILS: 100 HEREBY CERTWYTHATTIOSINt91WASCANsiRa1Gr®INA ANCEWerH
D D , H '"s'-O0 `�"'� °`►
AHa: alo,e�ATwcaP+roF THIS
a.TOTAL DEPt1E: 1zFROVIDEDICIre WELL MEM•t. b.DOES WELL REPLACE t0(ISiiNG WELL? YES(1 NW( .2 —7 _
C.WATER LEVEL Below Top of Casblg: 3 G9 FT SGNA of WELL CONTRACTOR DATE
(Use+I Above Topof Casing) ( ,/ .2' ' 5.' ,,I -
PRINTED NAME,OF PERSON THE WELL
Subidlt the original to the Division of Water Quality%/Adds 30 days. Atbx infoiitidlon Mgt., Form G1M-1b
1617 Mall Se ivhe Center—high,NC 27699-1617 Phone No.[phone] exit688.i Re+t 1?.107