GW1--08048_Well Construction - GW1_20231214

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,i"'stan "" T RECORD
+i Y R i itrE rx WELL CdNSTR
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I Y1, 'l ,*' I' • Nbrth Carolina Department•bf Ens wheat and Natural Rcsot roes DNmral of wS,ter duality
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Area coda R e number O �) . 7. GROUT: 146- l /
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.__ .2 WELL'INFORMATION - FL - — _
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STAfE WELL PERMITtt(It'op¢Ilceblet . 1 $lot Slxe M
g BCREEN. Depch t .
DWGl,or OTIiERPERh11T (if'applk able)' Frc 0J21 To$ . Ft In.. /a":!J in: .
WELL USE(Check ApplIcabie Box): Resid©ntial Water SUp• iy 0 • Fr._To,___•___Ft, • -
From_•._To • Ft., _in. in.
DATA t)RILLED ._ I .
TIME COMPL.gTED 10' d .. _ AM F' [j 0 g GR/\yEL'PACK
SAND(, 9
3.iNELL LOCATION: .
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/� Frorri�To"„ Ft
,;n �/N/COUNT- 44 '- Vtl From______::To FL
CITY ti._� -- + Te Ft.
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. (Stre•et Nome",:Numbers;Commu-ay,SubdM$lon;Lot No,Perce T)P"COO)
• TOPOGRAPHIC I LANQ ETTING: 1
DRILLING l tJ0
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:F ,rttation C3ea�xiplfori.
Cjgj pVnilay C]Rld9e QOther" •
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LATITUDE 61 01- minutes r /:
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LONGITUDE Z -��ti !�'
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tatitudLAOngitude source; XGPS oTop.ogrp.htc map- ��
(bce/Ion awoN must be shown on a USGS t , rnaP�.and .
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4.N1ELL OWNER /
OWNER'S:NAME . Li. G�D4' {
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' STREET ADDRESS
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( I1, REMARKS
Area code.+ P ooe ntmt>dr .. •
• • 5 WELL DETAIL• $: r - - -
p, TOTALDEPTNt /-
b,. DOES WELL REPLACE'EXISTING WELL?..YES,k NO.t]
1 too HEREBY CERTIFY THAT Tos W6,LL W,9 COµlo
3l TE0IM4tetA tt� OE Wrix.
c, WATER:LEVEL,BetowTop of Cesin4l FT. 1OANCAC A WELL
CO EDTO S WELL O Ra WTACOPYOFTM!8:.
(Use +^if Above Top of C,aalitg)
•
d; TOP pf CAS.WOG-
18 /- FT AbtY La{1d Surface
'Top of OesIngd®fmktated otter belOW.land curt ,. may requite SIGNATURE CERTIFIED WELL CONTI2AC70R DATE
a vitence ln
o .a.,O rdenCe with i 5A NCAC"2G.0 t a k .,. ..• .-
: '. .. - I / - OF PERSQtI CONSTRl1CTIN4 TWE WELL
e. YIELD.(tiPRt) G PRINTED NAME
Submit the original to the Division of Wata'r Quality wl hin 38 days
9� lA $at0fl Mgt a arm .ta
1,017 Mail`Service;Center-Raleigh,NC 2789 -1617 Phone.No (9•19); AS l=' j/i7)i" A
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