HomeMy WebLinkAboutGW1--04894_Well Construction - GW1_20230728 ,7....
. RESID TIA WELL CON tiCTION CARD -
- ofFsvirsa�lNaimal][tesoura: - Quality
' ,c _ Alm*Coroliaea Division of Warte.`-
IV. == WELL CONTRACrOR CERTIFICATION# 26 1a-
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1.WELL coPITRACTOR: d.TOP of PIING IS I ;/ FT.Above land Stye
ii / 1 Sin ;74� 'Tope as belowagar la land �r
require
- )I1 n. �h :i1; avarianceera 15ANCAC2C-0118..E
Well (irt�tridtmt) a.YIELD(gpm) Al.- METHOD OF TEST ST,-,'Pi
$.y.:fli L.J�f! ce. Kc. tr DISINFECTION:Tape /l r1/ Amount oLcti!„s
INA Contractor•, flame
STREET ADDRESS aka 3 olgtal.gz el ice - g. INKIER ZONES(depth):
From )b 6 To 167 From ' To
t 0'ri e,. Yd 02-7__-7 From To i Iron( To
QV trr Town Slate Ep Code From To FromTo
( 3 .} 3e r-ember
- 7. CASING: Depth D�rrater-7--
Area Material
code- Phone number - -
2.W WELL INFORMATION: From 0 To '7 Yv Ft. 6 'Ad -S P2J i�1'e.S//L
S17EWELl.1M aFP ? - From To FL
WELL CONSTRUCTION PERMIINgappacena'� ,�► r-as From - To Ft.
OTHER ASSOCIATED PERMIT e}rpawble) , 8. GRot1i: Method
3.WELL USE( Bob - ® - /� ✓�
Brad From ToL_FL /"x Ati- 6rzKA
IrligattWljj Matt gist use) A m el f- c _ Frock__To a a ,n cis '
DATE DRILI ED 5-2 2- ,2--3 From To Ft , •!
TOME COMPLETED S :3'n . AO PO 8. SCREEN: Depth Diameter Slot&re Malarial
A,.INEU.LOCATION:p To Ft in.. In-
C1TY- 1'✓1 a d"i.5 V" COUNTY/i D ck r.q1,,,i From To FL in. in.
y��� .8 a w /I. •J Fmm To FL in. in.
( ,:- Lott+ir:..Mal.Z Cadet 10.SAiID1GRAVEL PACKS:
TOPOGRAPHIC I LAND SETTING: • Berth Sie Malaria!
'nape®Valley to Fiat 0 Rldge t] Other From To FL
(d aRxmpiaala , Maybelodeems, -
LATITUDE /I of t'-,o Z 0. 9tv� mimics.seconds F1om To FL
LONGITUDE r.J c 5(7 •131 r eaadecanal mat _Form To Ft.
• Latitude&longibmde solace:�"GPS El Topographic map 11 FromRI1l.IiGTOS For:ration Description
gacalion°itself tnustbe shoran on a USGS bonbon apd 0_ ,—' L1 ia�chedto farmftwtusi1g.GP51 le
root, S
- 2- 2-5 rr `� ki ' .74`
a.FACLLIiY-test,armorearmeds ssrtesemamaisromtad.
FACILITY ID Alf ) ., -
NAME OF FACILITY Na . I,4ki e
STREET ADDRESS
r
. ja 2 8 2023 .
City orTown State - rro Code .. ._n 2,.---.0 .1 Ur.
CONTACT PERSON h r 1r d a.-reP(.J e- l( yfeCctP�C4010i 5 G
G ADDRESS )7/ 23cc,A. 0, P. - . •
!Y, eiiSah/fe {-1c. -17,32_a .�
City or Town State Z p Code . -
( 3 (o .)- 66G- 3-9)1
Area code-Phone number
S.WELL MAILS: 1OOHEREINC8t1rFYTHPainSINEU.WASCt rRUCr®eNA iaaa
15ANCIC2C.1WHs-oo1STRUcrrONffirrAN ANOTHEATaCOP1rCIF7HfS
a.TOTAL DEFIN: 2..5-- To wei-owi�L
b. DOES MU. EXISTING WW2 YEW Nt ` ♦' `� -ZZ-2.
g I `=rr=- fa.WELL CONTRACTOR DATE
c,WATER LEVEL Below Top of Cosmic ,/ 7 Fr
(Use+if Above Top ofCam) ta,4 Zi iv I�Ig -
PRINTED F PERSON � UC I GTHEWELL
. I1
Submit the ottigilvl b the Division of Water Quality within 30 days. Attu:hifonnatiaa PRIA, Form Crib
1517 Mail Seliika Colder-Raleigh,KC 276994 17 Phone No.(919)733-7Ot5 eat SOL! dear-12107
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