GW1--03897_Well Construction - GW1_20240628

ai • "N• RESIDENTL IL WELL CONSTRUCTION RECORD
i i - j North Carolina Department of Environment and Natural Resources-Division of Water Quality
d;Is e . g •
? ..-' WELL CONTRACTOR CERTIFICATION# 0-6 'Li a-,bra',-'
1.WELL CONTRACTOR: d. TOP OF CASING IS / FT_Above Land Surface'
// 1 'Top of casing terminabui at/or below land surface may require
v h w Ph .// Sm ; a variance in accordance wilt 15A NCAC 2C.0118.
Well Contractor«�. e_ YIELD(gpm): I D D r METHOD OF TEST,ii r) t Ye Ty
11,o ( paz Ya:f/i L/�l l ��. .�..c. f. DISINFECTION:Typep ii 1/1 Amount ,)- t u CS!
Well Contractor
rs sr:, Name
sTREE r ADDRESS a lc s l�'icz.R. el 4�{� g. WATER ZONES(depin):
From c/70 To ii?! From To
a-c 0 I a_i. n l= 7 U.X-7 From To From To
Cr1y br Town State Zip Code From To Flout( To
0.16,1- 4/3-7- VI/Z L�
Area code- Phonenumber7. CASING: Depth Diameter This srw�ht Material
2.WELL INFORMATION: From (,) To, 3t Ft, 6 4 , .9/:'2( P/a�i-
SITE WELL ID JR apse) -
WELL CONSTRUCTION PERMRa[dappicade) El-'fi P.2'1 cv-c‘y From To Ft.
From • To Ft.
OTHER ASSOCIATED PERMIT#(if app6wble) 8. Material od
3.WELL USE(Check Applicable Box)Mooaoring[J MonicipaliPubricn
From 0 To 10_Ft. PC I- 0, o,,•,i'i
Irrgaliore Mere (6st usrulturl D 'c From To _ FL e ;ris >
DATE DRILLED k - ,L C --1-y - From To FL
TIME COMPLETED :C o AMU PIg 9. SCREEN: Depth Diameter Slot Sze Material
4,WELL LOCATION:
From To in. In.
CITY: /Y] a i s z7 n COUNTY /�oc/ i. k-4 Ai From To In. in.
C 3 I3 c'L 1 cCr /1, i i - -- 01= From To _Ft. in_ in. ..-
( !Marne.Num Mae. bers.O rtanur ts/,5 .L t Ha,Parcel TP )
TOPOGRAPHIC J LAND SETTING: 10.SAND/GRAVEL PACK:
0 Slope U Valley El Flat it Ridge D Other Depth Size Material
(t appropriEte box) - From Toft_____4t.
May beLATITUDE .-.3IvD oZ' t / ow-4 o
u t� �� inadecimal � From • To FL
LONGITUDE Jd 75 35, (o Y/p
. Latitud&longi ude Source: ,W"GPS 13 Topographic map 21
11From �1G LOG
(location awe must be shown on a USGS logo map and From To Description
attached to this fo m ffnot using GPS) n- S �t C kr��h dP
5- 3 Z �roiJv.
32 - V 7 S I-a-n. :-ie
5.FACILITY-is the name of Ile business triers sieved is amb0. _ '
FACILITY ID tiff app5cabie) i _ -
NAME OF FACILITY ✓ I/► �A --
STREET ADDRESS (• , ,��' ..�.L..c.._V �`'�
-
City or Town State • ?Lip Code I L Ni 3 8 2024
CONTACT PERSON 3-c-A /'i ; f C r M a r rt.
-
MAILING ADDRESS 5-D 3 S k a.�f'- L a ✓� In(o:rn t4 'r'': 4'Ufa
isrrc :Isla tro 0C J7 1b 12REMARKS:
City or Town State Tip Code . .
( 33& )- la 13 ., 5.7— i Q -
Ame code- Phone murrber
6.WELL DETAILS: 100 HEREBY CERTIFY THAT TINS WELL WAS CONSTRUCTED W ACCORDANCE WnH
L/ / ISANCAC2C.WELL CONSTRUCTION STANDARDS,ANDTHATACOPYOFTHLS
a. TOTAL DEPTH: RECORD PROVIDED THE WELLOWNE R
b. DOES WELL REPLACE EXISTING WELL? YESU NC) 6 --2 t-2 y
WELL CONTRACTOR DATE
c. WATER LEVEL Below Top of Casing 6 G FT_
(Use+'If Above Top of Casing) ` / vI•L ; v"\
PRINTED NAME elF PERSON 1CONSTRUC.nNG THE WELL
Submit the original to the Division of Water Quality witllin 30 days, Attn:Information Mgt. Form OW-lb
1617 Mail Service(letter-Raleigh,NC 27699-1617 Phone No.[phone] ext 569. Rev.12/07