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GW1--00618_Well Construction - GW1_20240125
• • • • SDi[.eOxsrRu � crzeig cOlin NoithCarolinaDegai igEnvno -R11so mvouunafWatergad y - u - WELL CONTRACTOR CONIFICATION#: '19-A- " - ' ilYElt. Ot2- s and Pwnp, 11C. f. �T hT .A •2L n:,. • - -,g. -WATER (. .. • We!! .N .kma!Nance _ _ From `j®�_ o•16 o - Michael C*Sage - • _ . FROIRrom. Well C Name - . F -�---T� To Frorq To• 4Yrtttr ADORets 204 TOM Aire Fro'D— :T4 eYOe • NC 28429 From 7[ t3C5 c O `t- • Amo code- ieumber F ;,_To Phone SHE WE L INPOROATION - . ® quirk) B. GROUT Depth A . o - fF EwEt]._tiD• av e)F1 l` _ From To_3 '; i,ri N` .pl -�(ya Frar! To art ® wf AssocATPERi )PtNft�q` E = _ -- 3. u. JsE-ccookA Belo:-Repde Water - ;s. , slot /1 to.04.167*,.. in. rtre, -. ` . TIYECQIu�LE'tFp �`.�O AMI -• pMr - --Fra - � 'in. . ..: �. - • ' • ri . _To Ft`in. :b. cwt.!.Lf00J1TlOA: • «, I taco � - iaw�e . . . CO-COUNITY IJ l3�t 1(1 Q To �.�, - �. -153 (( k( l�n..- aL1ctc� _ From • g - esae.tNan a Number*,conn.,n$q on.Lot Para?�,t tej Fto+rt T°--._..._.,ems-_—� .,, Friom T _ 'R • T10POGRAPiNIC/LAND SEFtIN( • • I Stops.8 Paley-1 Flat {.(loge I Other . ; (fleet W 11.DRNG L(K; 1dYybeiadegrees, From To -- :' Formation. Dqn tATTtDE • i ONGnuDE,r _ inadd ford *-In re -- Y:`Tt- rl i�. ' LatimddMggiteidasorpvice; r.Gl'S S .a Tapgrit:map . l nofwean:1;4i*showtonaUSGSfop°oa�pand ►(�- 130 ; - 1' ('' TA .4-" 00.1•dVIN '• . _ .?neck d to th/sioan ffnotion'w GPS) _ .• - 5.WELL OWNER kA (, ) 1. L 30- I OWNERS NAME 1 \ ` �t C - ADDRESS QO 13eosie el S .frAS,.i IA,• .•• a-. —..,..., .,_,i ;c I(y orTowni to P Cody- • - - . _ . _ S.WELLbtu • 1x j ARKs: Y Q130•lyii .- a.TOTAL DEPTh J(F� - 4, DOES-WELL �NGWEIJ.? YES1 -• - gDott�Y rT_rrWwou.vos sr why - e;WJkit3ILEV© Belor�rT" of . .. 3•� - isi►t c war. °A - FT,' �1BiRUCODIE,WT pg AtD7HATACOPI'CF rriS ae+itAboveTop ) ' - - _ r'"s mlirEw�r d TOP OF CA-swats- • FC Above LeiniSaifaca• -i - - •'Tap of imeine tentaialed atfor below laaif:etKeee ma*'requi9 SIGNAluREOF CEfITIFl WELL-CONTRACTOR _ DATE et..var oe to vrmi t o NGA-2C.0118. .�(^ • - - e. ) S� : NETH0D OP TEST qV( Lt. PRINTED NAME OF PERSON-CONSTRUCTING Th:NE W I `- - -Suftthe Original to the Division Of W ► iaays. Alin:h et� nI Mgt; -. ,�i-�. -1e17 M GeMce.center- n, xia1T Phone H° ts1S):I33-7 a e;ti ..__