GW1--07270_Well Construction - GW1_20231109

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. ' _ R& ID N77AT WELL CONSTRUCTION RECORD
.s' • •;`-}r �° - - North CmolinaD�tofEnvire and Natural Resources-Division of eherQuality
.. . -sue,. WELL CONTRACTOR CERTIFICATION* 24 Ia..
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1.WELL COHTRACiOFb d.lOP OF CASING IS I I/ Fr Above L SIltisr* -
s,.5-IA *Top oft:asks terminated attar below land swine may requIre
a valance in accordattce with15A NCAC2C A118.
Well Contractor(trtd'nlidRtai) e.MELD Spud: oZ'' rams=OF TEST A r 40/07
1 N A:fbp $„,,:fl. L.1:_I1 eh. .r••c. f DISINFECTION:lypit 17/Ti/ Amount 2e,tio5
Well Contractor O6 nyName �I
STREET ADDRESS 2lo 3 1'lCL,.RL a L 9- WATER ZONES(depth): .
From To From • To .
• 17/0-`yj 0 Ia.., n R= o2761A.7 Frol To 1 From To
CdybrTown State Cade From To Finn1 To
• ( 361 3 m p 7 CASING: Depth I Diane dial
Area eacode-Phonee number m •
2.WELL INFORMATIOM From 0 To I/7' v, 1 e
q 6-AJO, ccIe/
SITEWELLIDSiamicable) - - From ' To FL
WELL CONSTRUCTION PERIAr(l earrnalle) .3 y a q
Ft
OTHER ASSOCIATED PER IIT ) . Et Ls�OITiL' Oap>fi Material Method3.WEIL USE(ChecicA le Box)Monitoring)]. M UPabltl t
IndustrialtCommerciaG
Fran To
11t(ga1kt14 Meal red :��13 M BS 7''Q L - F To J / '
DATE DRILLED R A - From To _ FL
•
TIME COMPLETED iv- / 3 Awn Pa' 9.SCREEN: Depth ' Diameter StotS'me Malarial -
4.WELL LOCATION: 41a� Tt L Emin S To � FL in. In.
I D'yb F',SI Mak Rd 270572r From To i ; Ft in. in.
• (Sou t Name.timbers.Coma Sub n.tot Ma_PAWLTPCode) i0.SAND/GRAVEL PACICe
TOPOGRAPHIC J LAN •D
0 Slope L]Valley 0 FlEd=1 Other Depth Size Malarial
(diedcapproprinteburg • frtyri _To L
MaYbem icials. from To FL
LATITUDE _ minutes, rdsor
LONGITUDE__ madeci�lfomrat From To _ Ft
sourc GPS 0 ToPo hic 11.6RLLLING LOG
�P •
Lalitudellongibade
(lbe0ar►ofweUmuatbe shown on a USGS tape inap and r —j 4- ' Gray-n,'f From To on on
at m attached fnotusing,GPS) _ T
5.FACILITY-r5 the norm eineadnesswme mewl]isloWea. I•
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FACILITY 117 8(if app ) MI O Z073
NAME OF FACILITY • V n I , .ti - : .
I tut
STREET ADDRESS '•=':°�:,—
2-3
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City orTens' State , ' Zip Code -•
CONTACT PERSON I(e. ;'f k )'I/�e 4.1
- - MAILING ADDRESS l 67 4 1: i SL`e r,vi a h XI '
I
W ci ii,o- e o If L n C .17 6 5z- 12REhlARI .
City orTown State j �CodeS e Li- p V e r• D C he-n r0 M a S ha�
• A 331 r• (n /tunber - e Ls� ! e.
Area Code-Phone murber rim n rG C c a C
E.WE LDEiAILS: IDO HEREBY uT'rt rc ElaWYTti�sw MOMS c314stt:uctlroeaA WITH
15AHCAC2C.WEILOONSrROC ION STANDARDS.ANDTrWTACOPIfWINS
a.TOTAL DEP11D ,S 2 i- / R •;. PROVIDEDIU E WELO NER.
• b.DOES WELL REPLACE EXIS1UIG WELL? YEWNt // f - /b-b-.2-3
SIGMA - WELL CONTRACTOR • DATE
rr WATER LEVEL elowTopofCasinF e 7 FT_ /� r
PRINTEDNAME
(Use--efAboveTopoffeing) • P� /1`n £ :tL -
•
- PRINT OF PERSON CONSTRUCTING THE WELL
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Submit the erighid to the Dirttt;iiall of Water Quality within 30 days. Attn:hdatnt4on Mg. Form GIN-lb
1617 Mail Service Csuder—Raleigh,t4C 276994617 Phone Na(919)733-7015 ext * 1 Rev.12i07
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