GW1--04888_Well Construction - GW1_20230728

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• ' _ . ESIDJ1VTIAL WELL CONSTRUCTION RECORD
t-r��: -4 = ofEnvironme tendNalivalR+eso Resources-Division aterQuallty
--4. .f �' North Carolina .
' •7A., 4T" WELL CONTRACTOR CERTTIFICATION0 2 6 l� �
1.iNE LL CONTRACTOR: d TOP OF CASING IS ! / FT.Above Land Surface` -
i !J I / 'Top of casing terminated a►�belowland surface mays •
J n. �h ;// �in , a va in accordancevw�15A NCAC 2C.0118.
. Well Cwdractnr(Individual) - e.YIELD(gpro): 7 METHOD OF TEST gr ./20/61
.754,r A•://.- $....:f/i L.J,. /l no. Xne. f. DISINFECTION:Type 4 /I-I Amount 2 a'95
Well Contractor tame
STREET ADDRESS ak 3 1Y1rLn.r4 el etCe g. WATERZDNES(depth):
• From 5-5- To 6' From - To
• ,y�ry 01a-,. h 7 From To .Rom To
6r• Rom - To From To
• 0363. q3-7- yyz& 7. CASING: Depth Diameter Material
Area code- Phone number
218E11 RiIATION: From D To ZZ' _R. 6 V s.)2a.i pAsi'G
WE WELL m Off applicable) Rom To FL
WELL CONSTRUCTION PEIDIIIi en+>l 1 fl V P a ZDJ P)� Roin • To R. .
OTHER ASSOCIATED PERMITI(ffapplicable) . 8. GROtii: DePth Poo-3.WELLUSE(ChedtA�BBox)! O Ihmicipaingticri
Method
Agricultural, From 0 To D FL e r a, li
Irr�gal Otlr orf edi (Ost use) o AA-0,5 i eg- _ From ell To l o FL r�/.vs '
DATE DRILL LI--/ 7 - 3 From )Y.T To ..a o Ft -
TIME COMPLETED 3 6 0. AM13 Ph5131 9.SCREEN: Depth Diameter Slot Wm Material
4.WELL LOCATION: /� From To Ft. in. in.
• - CITY_ • -5f t,n e_ d'//( COUNTY/ kck:nf vn From To hi. hi.
/t�-0 (i vice /2.ee S/-one v://'e From To FL hi. in.
(Street Name Numbers.Caraaraa"l9.Subtruf .tact Na.Mel Tip Code) iQ.SAND/GRAVEL PACK:
TOPOGRAPHIC I LAND SETTING: • D Sae Material
Slope U(check bin) Other Firm To FL
' Mall=i°d_► From To FL
LAM/DE ,�• ' .2 N,2-1 , mimes. or From - To FL
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LONGiUDE: t�0�y ,�° 5, in adecimal rminat
Latitudellongdude source:%GPS El Topograpbic map 11 Rt11.U1GTo G Formation Dt aiptian
gammon ofeel/must be shown onaUSGStomomapand Fiximp_ 7-a� © : /
attacbedto 11 isfarm drratusulg.GPs1 � 0z- . 1/m..,Sk e/(
3.3- 90 ' G ra.z Ht.-
5.FACiLRY-fe the nam enhebmrnessubneTheiseiisiocal Li)— tiff 2 ece .Si(e/(
FACILITY ID Wrfappal le) Nk-a1.:2 c G ra-n '>`t -
NAME OF FACILITY r - �; .
S1REETADDRESS
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• CSjraTo i state ZpCode _ - J'JL 3 2023
CONTACT PERSON 8 cs¢ 13 u 7)6[e rS lnfcarra.,.:+scr Prr-, a A Una
MAILING ADDRESS /`t ��3 .
-S r,.nn far f el d' i) c- 2 73 SS .
Cay orTovm State 2p Code
( 33le )-. (12-7 - %81� -
Area code-Phone number
8.WELL DETAILS_ 1aolraB3YCERnFlrrw►TTinswreiWas CONSTRUCTED RUct:OttoAraCEwnH
/ 15ADICIICa r-�ST THATAC�YOFTIm
R.TOTAL DEPTH: -2 6 5 RECORDrz PROVIDED THEW�l.t
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° b.DOES WELL REPLACE EXISTING WELL? YESU NO% . LFED i 2J
g.WATER LEVEL Below Top of Casio' ' 0 • FT SIGNATURE a� WELL CONTRACTOR DATE
(Use+If Above Top of Casa) • fn , ;/ le , v�
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PRINTED NAME O PERSON CONSTRUCTING IHE WELL
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Submit the original to the Division of Water Quality within 30 days. Alto:Infommilion Mgt Foam 1338-1b
1617 Man Service e Off—Raleigh,NC 27699-1617 Phone No.[phone] ext668.1 Rav 12107
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