GW1--03658_Well Construction - GW1_20230526

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yam-FHEs7nr, Eo�"°P,. RESIDENTIAL WELL CONSTRUCTION RECORD
>€ North Carolina Department of Environment and Natural Resources-Division ofWater Quality
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`� �,'' WELL CONTRACTOR CERTIFICATION# 3 3
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1. . ELL CO TRACT R 1 , F.DISINFECTION: Type:C-I a lz l/it Amount 0Z
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11 I l � W, j'•IC- .144) . l)D G.WATER ONES(depth)• 1
_ _ ,_ From 1 WeI Contractor(I4-QL
vidual) me = To i From To
CA.2c��'2_ )x . I3! LII III From To From - - To
Well Contractor Company Nam From To From To
STREET ADDRESS�'13y t ,-t- . 1{\,� ' V"� 6. CASING: Thickness/
�-�/ V� 1(-1 3�3 Depth �" Diameti Weight Materialfoe—
cg:Pc,City or Town State Zip Code From To �v Ft & 2.)•&
' 3 S qcz?43 From To Ft
Area code—Phone Number From To Ft
7. GROUT:
2. WELL INFORMATION: Liq I S� I3 I 4-( Depth •1 Material Method
SITE WELL ID#(if applicable) —f���i — '7� n —
STATE WELL PERMIT#(if applicable) �S ' c� 13" i — —mom 0 To L1 Ft_LSQ��1( 3=(2 v �^ . __
From To Ft
DWQ or OTHER PERMIT#(if applicable) From To Ft
WELL USE(Check Ap iccab e Box);Residential Water Supply 0 8. SCREEN:
DATE DRILLED 9 .3 Depth Diameter Slot Size Material
TIME COMPLETED , 30 AM❑ PM" From To Ft in. in.
From To Ft in. in.
3. WELL LOCATIION:[[ ll , a$ a�
C TY kel Q l)i4)r A 11-2�`Wqr From To f-t err. ;a $r•Till
COUNTY 9. SAND/GRAVEL PACK: '` M
c� i.,)=a 10 TQ 5�1 K y -d 93 C Depth 1•�ec� aterial
(Street Name,Numbers,Community,Subdivision,Lot No.Parcel,Zip Code) MfT 2 E ZOLJ
From To Ft
TO' GRAPHIC/LAND SETTING: From ToInfOicatitil PfC1144P4AM UN
r! Slope 0 Valley 0 Flat ❑Ridge 0 Other raA ,*j or;
(Check appropriate box) _ From To Ft
LATITUDE b L u7 -7S 10.DRILLING LOG
9 From To Formation Description l /
LONGITUDE l� 3 �itoki / ,SO L 4, L-0
Latitude/longitude source: GPS 0 Topographic map 3 1 1L �/tG 1L �--"
(location of well must be shown on a USGS topo map and
Attached to this form if.not using GPS) 7 Z° -� It46/(7 .ter,.-4S/ ,
7,,vd3S z CAL , L .
4. WELL OWNER �� I •l Z� ���� �2GvY])
OWNER'S NAME 7C:ti'll i'e- 1-1✓ Q Z" 3s
Li/ v If- )
STREET ADDRESS �+ o� R pi ‘‹ ),,
i�
�rYA 1 c'2.- NC a.g 6 ).3 i
City or Tow State Zip Code
`33( .(�t.) ao`73—
Area code—Phone Number
5. WELL DETAILS: A ,A 0 9
!.-[ 11.REMARKS:
A.TOTAL DEPTH: f
B.DOES WELL REPLACE EXISTING WELL? YES 0 NO D/
I DO HEREBY CERTIFY THAT THIS WELL W CONSTRUCTION IN ACCORDANCE WITH
C.WATER LEVEL Below Top of Casing: 3 0 FT. 15A NCAC 2C,WELL CO STRU 0 STA RDS,AND THATA COPY OF THIS RECORD HAS
(Use"+"if Above Top of Casing) B OVID D TO TH ELL 0 ER.
—
D.TOP OF CASING IS & FT.Above Land Surface*
*Top of casing terminated at/or below land surface may require SIGN TURE F CERTIFIE WEL cON,TAAcrOh . DATE
a variance in acc dance with 15A NCAC 2C.0)118.0 71 /t it_ fill11 1'b' 3—'._i 3
E.YIELD(gpm):_� METHOD OF TEST h ).r PRINTEDJJAME OF PERSON CONSTRUCTING THE WELL