GW1--07271_Well Construction - GW1_20231109

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.1?1ESIDEM74L wELL CONSTRUCTION RECORD
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. :-"--:_r•y, I - 140011 CesorniaDepadment ofHavirooment andNelmal Resources.-Division otWater Quality
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. ' - WELL CONTRACTOR CERTIFICATION it 2-6 'T/4.- .14
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1.WELL COMRACTOM d.11DP OF CASING IS I I FT.Above Land Surface*
Ta 1,.., PA :Vizi-2n ;'ill 'Top erasing terminated atior beim/land surface may require
a variance in accordance war 15A NCAC 2C.0118.
Well Contractor(Individual) .
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e.YIELD(gpmt METHOD OF TEST di,- le,/
5:1714 es A:lb, &vs:IL 1....)&11 et). ..z..c,
E DISINFECTION:TypU . // 77/ Amount ..1-c(16
Wen Contractor Mrnmly Name I
STREET ADDRESS az,3 pia...a.u.e./ Le - II- wAIER ZoNES CdeP,tb):
From 9s To cii if FiornTo__ _
• )11 c-,61 0 hia.4-.. n c. a 70A.-7 FrUm To i From To
QV&Town State Zip Code
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• 361- 3-7 VV .& From • To_ _ Fnan __To
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Nee code-Phone member • 7. CASING: Depth Diameter ThiduandWaigla Material
&WELL RWORMATION: From 0 To V/ FL ir Sa-4/0 Pie,s//2-
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. SRE WELL ID faappleable) - From To Ft,_ ____
WELL CONSTRUCTION PERIMIN(4appEustge)fl 0 P23 Co 3-44 From To Ft.
.. OTHER ASSOCIATED 13ErGAItifflf i*Pricable)T -' - - '-'------ -- - • , _____ - -
3.WELL USE(Check Appffrxdrie Box)Monnoring0 PAndripagpubren •L GROUT= DePtil Material Method
InductstatiCoromercia' t0 trujectionil From C) To q R. Po )-1-16,1.4 Pe,,-40
InigationD abed! (rut usrulturwiR7:71,1! From To , Ft,
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DATE DRILLED i q 7.2.-- From To ' FL
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TIDE COMPLETED Ii A . . Mil FMB 9.SCREEN: Depth ! Diameter Slot Sue Material
4.WELL LOCATION:- crr: $An e.a 1/ COUNYA,cM,1
Brm Totin.
, From To 'l ± in.
in. in.
a a/4.r K 77' / 02 7 v yE/ From To I . FL in.
• (ntlael Name.Numbers.Commonly.SubdviSial.Lot No..Pdr, , Tip Code) i.
TOPOGRAMC/LAND SETHNM • 10.SAND/GRAVEL PACK:
0 Slope El Vane!!III Flat/Aldo D Other - Depth To vi. ff__ _ Material. -(d ria-to ock appmp box) . il ffromMaYte in( ea.
LATHUDE IL36-1 .2.-9. //7/ ininutes.secontis or From To
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From To i, R.
LONGITUDE I)013° 5'5-, 3a 7.1 in. adeanial Ramat 77—
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• • . Latituddlongitude sow=AMPS 0 Topographic map iiimuume LOGFrom To Formation Description •
aoCarkiti child,mustbe sfrovar on a GM topO inaP aga •
attachedfothisfam)ffnot using GPS)
8.FACILTill-tatutnamoinebusinessunese itheiteD is locelml ,
FACILITY ID It(lielPPrwable) ,. _ NO V t) d 2n23
NAME OF FACILHY • ir,r2T:-.-....:', • ..., '
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SIREET ADDRESS i A- • .....„ . , .
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• Cily or Town State rm Code - •
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CONTACT PERSON_ 1 o 4 ert td y 44/--
- MAILING ADDRESS P 0 & x
SivAe I/,-#9 tic A'7o yIr 12 REMARKS: ! ' .
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. Cily or Tovm State Zip Code _ e 4, le " I
• 3,)69 )-. 9-3 7- - 7 )ta .
Area code-Phone number i 7 A frirmillinfof allearMaggillir-e ,e
S.WELL DETAILS: too mew cernFrnaritut waLwas-- -) =.IN ACCORDANCEINMI
. 15A MAC=Vi131.CONSTRUCTIGH STANDARDS:ANDIKATACORY OF TIM
a.TOTAL WPM /5",2. / . RECORD HAS. PROVME91HE WELL OWNER
i ;— .-------.. - i-2-2-3
b.DOES%VELE REPLACE EJOSTING WEU2 YES© Ngef 7 i.
SIGMA WELL CONTRACTOR DATE
c.WATER LEVEE Below Top of Casints 1-i D FT.
(Use--e if Above Top of Casing) •
Feel;0 ---C/1-4 :./.4__ -
NAAW OF PERSON •W ,,I4aUCTING THE WELL
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Submit t Qua h
he original to the Division of Water llty wilidn 30 days. Atm:mioneanon Mgt.. Form GiNalb
1617 Mail Service Center-Raleigh,NC 27699-1817 Phone No.[phone] art 668.1 Rev.12M7
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