GW1--05787_Well Construction - GW1_20230901

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SID NT AL WELL CONSTRUCTION RECORD
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IJ L t a North Carolina Department of Enviroinnent and Natural Resources-(D/division of Water Quality
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.,.,,,,.�: - W�L$.,CONTRACTOR CERTIFICATION '�4/
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-- f. DISINFECTION:Txe Amount C Gl
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Q e a`L � L 16lA 7sa f g. WATER ZONES(d th):
ividual name ( From tJ
o _ From To
WeA Corrtrador(, �7� p, f / ��l��h)� From o ; From To
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1 ,4 !J"�- / ✓ Frain To —
From To
Well Contractor Company Name �+ Thickness/
� ! 7eoo g-t LIA r 7. CASING:e1 ' l
STREET ADDRESS r I p�v Frain 1/ To� Ft. �� ' • ( Hai./4_
t r< Zip Code From To FL..
City or State 3 _ From To ' FL
�j6 too)' o��ry'���f Method
Area code- Phone number S-GROIiT: Depth Material
a.ifc'ELL INFORMATION:
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2 From O
To Ft
,PJ Prip
_SITE WELL ID VappliczC'e - - From To Ft._ ________
WELL CONSTRUCTION PERMiT# ©5_ f(iN7,atTff , •ch '°E U .From To FL- --
Del`.C.J'l3`3
OTHER ASSOCIATED PERFAITRIf aPplicab;e) 9. SCREEN: Deptho Ff. in.Diameter Slot Size [tetanal
in.
• 3.WELL USE(Check Appt"rcatite Box): Residential Water Supply O 3 From To FL in. in.
DATE DRILLED `� From To I FL in in
TIME COMPLETED 'e�0 AMC � `
10.SANDIGRAVEL PACK: . Sine Maternal
4.1�iELL L®CA Old: G�CG�.�I Depth
i.11fahe s COUNftY From To _Ft.
CITY. j From Ft._
�d / ;�C'�i�r� To To I Ft�L.Cc dt/ Code) From
(Street Name.H .Commonly.S�:orro+san,Lot Alo,Fares Zip
ICI LAND SETTING: Other •
St� Vary a Flat I R dge 11.DRILLING LOG Formation Description
(check��ti !� May be is dags�, From To
LATITUDESSCJ mom,seconds or k
in a decimal format
LONGITUDE-- 7 y <9
Latitude/longitude source: B. GPS a Topographic map d
(location of well must be shown on a USGS topo map and t9 C! /,O �' ��e
attached to this form if not using GPS) . T y
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5.WELL OWNERn
OWNER'S NAME �r / 4./'Zo e% i
STREET ADDRESS
City or Town State �r Code � � •
(.WELL
DETAILS: 12. RE11rfAR£S: f j+ / ` r�yL/d..
Area code- Phone numbe' r
b.WELLALEP p
a. TOTAL DEPTH: ` _ wrTM
b. DOES WEt�.REPLACE EXISTING WELL? YES? NO: lEt NCAC CERTIFYCONSTRUCTIONiHIS WEU_WAS RECORD �ST THAT A OE'NIS
c. WATER LEVEL Below Top of Casing: FT.
G
(Use-¢'if Above Top of Casing) ` �'a�
Land OR DATE
d. TOP p CASING IS Si RE OF CERT FiED WELL CONTRACT
°Top of casing terminated actor below land surface may require 01 ��,,i't
a variance in accordance with t 5A NCAC 2C.Ot 18. CV e e- Z
4 e. YIELD Wm):___ __(2—
METHOD OF TEST a / P INTE NAME OF PERSON CONSTRUCTING THE WELL
W-la
Submit the original to the Division of Water Quality within 30 clays. Attn:Information Mgt, Rev.Form G
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 568.
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