GW1--05786_Well Construction - GW1_20230901

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North Carolina Department of Environment and Natural Resources-Divis fon of Water Quality
'''''''''—'4:• -- WELL CONTRACTOR CERTIFICATION# r
1.WELL C - OR: f. DISINFECTION:l9pe Amount/1 C L 'r
� L. , /P,1 %!f/ain� g. WATER ZONES(depth):`
�f//y F� P() To w0 �- From To
Well ntr(Individual)Manse From
From To
�n y c/IJ�'
�4�� ✓1 � � U,� �e€� �`�� From To From To
Well Contractor Company NameThickness/
!'L?_ S� �f r 7. CASING: Ma 1 ,
STREET ADDRESS c From C� tiaar ��
�y Mate From To Ft.
State w°G Ft
City or T �+, v,. .., From Ta
f..:i - n
Area code- Phone numberMaterial, thod
2.WELL It�ORiiRATION:
S E P J 2024 8. GROUT: Depth • o 1- fa tad UP/
_SITE WELL ID Ike oppi=We ,. , �:� i From From To Ft---
1 7 ' FL__�__._
WELL CONSTRUCTION PErc(vis i� �" }"
Depth Diameter Slot Size Material
OTHER ASSOCIATED PERt1dIT#(tf applicabSe) 9. SCREEN:om o Ft. in. in. —
•
• 3.WELL USE(Check Applicable Box): Residential Water Supply f3 From To —FL in. .in.
DATE DRILLED `! r �r From _To I Ft_ In. in.
TIME COMPLETED 1 % d AMfl 6 '
10.SAND1GRAVEL PACK: . Sim Malaria!
4.WELL LOCATIOid: Depth
C'lY: M,04e7 ` S COUNTY L GG'ti From To ! Ft.
r . `r f4jticll' From To Ft.
2h C�4 y /�� � To Ft
(Ste m nnmi:y
Nae. umbers,Com .Subdivision,Log nel
No.,Pa ,Zip Code) From
(-- r ICI LAND SETTING:TING: ear '
9 Slue Valley li Fiat Rl R dge 11.DRILLING LOG/A Formation Description
(check appropriate ) , grses, From To
LAT{TuDF zgr-o Nifty be in da OIIse or
/O.t in a dial format
LONGlTuoE ��"a'l' E7.
Latitude/longitude source: a GPS a Topographic map
(location of wail must be shown on a USGS top map end i ' � Aw l
attached to this form if not using GPS)
1.OWNER'S NAME
STREET ADDRESS
City or Town State Zip Code
• (._--)- 12. REMARKS: L� /jj C' 0-1- fir'
Area -Phone numberGJ !JR'
• •
C.WELL DETAILS: I Q G. ei /t
a. TOTAL DEPTH: WITH
ta. DOES WELL REPLACE EXISTING WELL? YES a Oil i5A INCAC FY THAT THIS_CONSTRUCTIONS AIMARDSTHAINAS CONSTRUCTT A COPY OF TWIS
NCE
c. WATER LEVEL Below Top of Casing:
0 — FT PRovi Ep To TriE omen. i �'r��
(Use'+'if Above Top of Casing) -
d. TOP OF CEASING IS FT.Above Land Surface' RE OF ERTIFIE/DD WELL CONTRACTOR DATE
°Top of casing ed at/oh 15A land surface.8. require !'Z i fri �l/f� '
a variance in accordance with 15A NCAC 2C.0118.
. e. YIELD(gpm): /a)' METHOD OF TEST i l r PRI NAME OF PERSON CONSTRUCTING THE WELL
•
Subna'tt the original to the Division of Water Quality within 30 days. Attn:information Mgt, W-la
Rev.Form G
1617 ail Service Center-Raleigh,NC 27699.1617 Phone No.[phone] ez4 568.
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