GW1--04893_Well Construction - GW1_20230728

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. 'RESID 1 h1 L ,CONSTRUCTION RECORD
. -��, � North Caro]�Department ofEnviranmdt ldN�al Division of WaterQuality
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WELL CONTRACTOR CERTIFICATION a-6 s1a.
1.WELL COHTRALT01t; d.TOP OF CASING IS 1 / Fr_Above Lend Surface` .
i/ 'Top of casing after below land rye
,%� ��r :Than �ia7 . � aea inaccor�mew 115ANL'AC2C.0918.
Wetii Cortbaetflr(term 'J
ea.YIELD(gg�?: S METHOD OF TEST %��0 k f
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f. DISINFECTION:Type /17f-/ 1 c"p5
Wen Contractor O6tpazry Name
STREET ADDRESS 1. ...t,z.l IC! - g- WATER ZONES(depth): y,
From To - 1�r ht - To
COj i,.1E3., I'1 L a7U:�.7 From To�`'' ROM To
O trTown State Tip C
C SLa} 3-7- 0/2-LP From To From To
Area code- Phone number 7 CASING: Depth Diameter Material
&WELLINPORMATION: From Q To 9/9 Ft, f'` S.1-Yb P/&sfe
Sii'EWELL LEI t ) - From To Ft
WELL CONSTRUCTION PERNIM app®ea>ie) zrvieP,2,3,S-o! _ From : To Et
OTHER ASSOCIATED Pt:RMIT ) 8. GRO1R: Depot Mattel Method
3.WELL USE(Check Bob ® ublo
tojectionS From 0 To 17 FL POr'//G7y Ppuret
[MOM' Gamin .(Bst hue). it rr►e S it From__To R. /S'k
DATE DRILLED 1 R 7 S' From To FL
TIME COMPLETED • Mtn PMi7 9. SCREEN: Depth Dial StotSi a Malarial
4.WELL LOCATION: Eton; Tp p(Z in. in.
CITY_ .‹TOn ee d:�/ COt3i�T6Ye!c/�:�s l.4 irr From To f a in. to.
J6 LI I':nc.k14.N$7 ui( 3-7bz-/E( From To R. in. in.
(Shed Name.Numbers.Cammemisr.Suberotket Let tie..Pd d.Z'epCede) W.SAND/ RAVEL PACK:
I SETTING: Depth7iSete Maul
D Smote U Valley I! Ridge U Other
(che appmedide ck - Horn To
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2r C R9apbemdegsets` From To Err
LATITUDE �, 2L._.s(.`a�� rains .s or .
LONGTIME
229 0 5a. 6 y D in ode lrmenat From TLONGTIME
. Latitude/longitude some GPS A Topographic map tt.rRiLui�LOG
(tocetianofmaitn t sin on aUSGStopoirwpand From To , Fa Description
atiadmdtoihesram►Thant ueng.GPS) C/�e, s e 11
S.FAC .Tflr-raise narneceitbebtaktassuheretheirtilistoward. P "r .i" 'f kit -
FACILITY mfigi ) A- - .IEEE 2 $70�
NAME OF FACILITY /(1
STREET ADDRESS OnfcreraJ11
Rtsn?�++.-.--'�..v,"'•3 l;r.
CilyorTown State/ . Zip Code _
CONTACT PERSON 2-u h t r- )4 //
MALING ADDRESS I t Y P%n c h a,svi N/Z .
-$1ni cu.)//` h L 017o 5 ? 12 � -
CrlyorTownt State C 7t 6 ,, ed a Ml 7' G�c /( bit e le c°a S.hs
(33(0 ). -540 -- S6Cpy - ,p, u <¢ ,L rcd 90 ' W, .as
Area code- Phone number r
6.WELL DETAILS: i co traREGYCERTIFYWAYTHWIELLWASCONSTRLIMEDaeAODORDANCEwmt
TRIS
a.TOTAl.OEPTfC
00 ' ' `nE L .rHEWEr ow alp,reAfA v�
b. DOES WELL REPLACE EXIS11NG WELL? YEW NO SIGMA
WELL CONTRACTORS TE��
c.WATER LEVEL Belot Top of casing I $ I F
(ldse'+'iT Above Top of Cam) i/ 1t,'// le �rI,I. ,T
PRINTED NAME OF PERSON CONSIRU(RNG THE WELL
Submit the original to the Division of Water Quality mettle XI clays, Attn:men:lame Mgt. Form
1617 Ilan Service Raleigh,RC 27699- CPhone No.(919 MS ext 668.! 1 It►
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