GW1--04896_Well Construction - GW1_20230728

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'RESIDENTIAL WELL CONSTRUCTION RECORD
. �4 .cry� Noral Cardiaa Department ofEnvimammt andNlabual Resources-Division o€Watrr QuaIty
• . ;�, WELL CONTRACTOR CERTIFICATION# 3 6 pia_l
1 i
1.WELLCONTRACiOR: d.TIDP OF CASING IS I l Ft Above Land Surface•
. - )k n. Ph . /1; S- 1 ;iI 'top oft:sing attabelow land surface may require a variance in accordance 15A HCAC 2C.0118.
Well Contractor(trrtfnridrsai)!fie e.YIELD(g pro): �� y� MEIHOD OF TEST i9 r RD)101
g r :ff.° S;,n:f4 t,Ja/, cad_ .cc. f. DISINFECTION:Type /OW Arm i e uPS
Well ContractorCbmpmCy Name -
STREET ADDRESS ck 3 r,.t,e J Jee - g. WATER ZONES(depth);
Ram Gs To !v o Rom - To
PI it y0 et h n c.. .17,9 ..7 From To From To
C ybrTown Slate rip Code From To Ftorrt To
Area 1- �7 u VV 7. CASING: Depth lli� Material
Arm code- Phone chamber � _
2.WELLIELLIDA(ION: From ) To 1 71 Ft. &r1% S I)R 2( )9/0-S is
SITEELLIDIffa:mg:abre)W From To Ft
WELL CONSTRUCTION PERMf;ii ) ffL?P.23 6l0-CD? Rom . To Ft.
OTHER AssoA-rep PERM rr (wep amble) a e Material Method
3.WELL USE(Check A a Box) O .
MT: Dell%
From O To D Ft D Icn piar
Irrigation] man (ist ISS) r1 e s/tv F To R. c"`t'-Ss
DATE DRILLED Co -a P^-2 3 From To Ft.
TIME COMPLETED ...1. . D ©'. Ali 0 PI 9. SCREEN: Depth i Diameter Stet&re Material
4.WELL LOCATION:• T Ft in in.CRY_ Gt . so,— COUNTY✓1dc1(,ti �c•K DIM From o FL in. In.
a...ci I 4.-i- j CA. eL. • oa7b2 S From o FL in. in.
(Su ron et Nerve. ant s. s„b .Ltd ram,Pacer.Zip Code) 10.sANDtGRAVe.PACK:TOPOGRAPHIC LAND sErrtrlG_ Der Size Material
o Slope LI Vaatn yirRat I] Ridge U Other
(check appeopiita hat) Einm T. FL
LATi1UDE ' '�d 0 . 07 �� MEI7 be in fie/ices.
mimtus.seoandsor From T.' Ft
LONGITUDE✓®29'P =3 5.. 9 g 9 in adecimal°Mat _From To Ft
• I.atitudellongr de sour:,R'GPS 0 Topographic map 11.DRILLItsIG LOG
From To Fin Description
(bcabonofet+en must be shown mra(MS logomapand 0_ GQ . C I��
attached tof farm aYrrotrrsih9.�S) - ar,Z,s ; ,.,1-
S.FACILITY-isme=Ra ian buMassmaterethewellisload d.
FACILITY ID gif applicable) ..• _
NAME OF FACILITY Jf� I"! ��,1"'0 i
STREET ADDRESS in k- J
•
• JI 1. 9, 87023 •
QV orTown State 1 ' Code
CONTACT PERSON Ca-S7 I.�ZJ dec Sm* A initcrr.:+gin orr,: •4JUr.
- MAILING ADDRESS 3 D/ so_r^ol;s c N• ex
Ma. _
Ll i S N L v 12.REMARKS:cflyorTown State Zip Code . .
" (-33 to )- 702 ' 95-0.3 .
Area code-Phone number
6.W8.WELLMAIM roo HEREBY cSFalFY MAT THIS WELL WAS c TEZUCTS)IN ACCOSOMCE WWI
a. TOTAL .�� _ IS NCRC2C.WasCON UC1raaSTAND ANDTHATACaY OFr
MOROI= PROVIDED7C1THEWELLOWrSt
b. DOES WELL REPLACE EXISTING WELL? YESU NO/ '- N�-�
c.WATER LEVEL Below Top of Gasbag V b' FT_ S�NA OF WELLCONTRACTOR DATE
(Use a'If Abate Top of Casing) • I�iTED //•` , S•n ;-111 -
PRI NAMED PERSONCONSTRUCTINGTHEWEIL
•
Submit the ciniginaf to the Division of Water Gaudily ends 30 days. Attn:Informaition Mgt., Form e'W-lb
1617 Mail.Sue 4 —Raleigh,NC 27699-1617 Phone No.[phone] ext 668. Rev.12197