GW1--04461_Well Construction - GW1_20240730

°`SN" oArf° RESIDENTIAL WELL CONSTRUCTION RECORD
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ft" North Carolina Department of Environment and Natural Resources-Division of Water Quality
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�y, WELL CONTRACTOR CERTIFICATION # �o l A-
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1. WEL ONT CTO F.DISINFECTION: Type:C/Or�I L
Amount / © 0
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( I l Q'r1 G.WATER ZONES(depth):
Well Contractor(Individual)N e l From 2-0 D To 2-1 I From To
C l e 4 it i'v►q-k'Z V�I/1 l/1y ,42 From To From To
Well Contractor Company Name //, V h From To _ From To
STREET ADDRESS q i 3 it,N%r� 6/1/-it Pei 6. CASING: Thickness/
4�/it-X /4 24333 Depth �j/y i Diameter Weii ht Material
City/or Town (/ State Zip Code From d To /(f Ft 6�� �/ ' P‘
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274 _? -3 7 sO From To — Ft
Area code—Phone Number From To _ Ft
7. GROUT:2. WELL INFORMATION: ,/ j /�Depth I M/��T�er: IOU
SITE WELL ID#(if applicable) d 7 C / 0 To - Ft Z.zC/10ire- I �^
STATE WELL PERMIT#(if applicable) 30/)../,3 7 2_1 4 From `� _
/ From To _ Ft
DWQ or OTHER PERMIT#(if applicable) From To _ Ft
WELL USE(Check Applicable Box);Residential Water Supply 0 8. SCREEN:
DATE DRILLED /..2 2 2— a3Depth Diameter Slot Size Material
TIME COMPLETED AM 0 PM la/ From To Ft in. in.
From To Ft in. in.
3. WELL LOC ION:
From To Ft in, i
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CITY:> //``, C�`�'eKCOUNTY A//1�I 1qn g, SAND/GRAVEL PACK: — `.-`.�'.. r f��
Co , � f-�V � Depth Size Material
(Street Name,Numbers,Community,Subdivision,Lot No.Parcel,Zip Code) From To _ Ft jUL 3 0 2024
TOPOGRAPHIC/LAND SETTING: From To Flirfo:xti-i. P-,74-3{4.;-1 UM
❑Slope 0 Valley 0 Flat Ridge 0 Other — ' ?' C.4.;
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(Check appropriate box) From To _ Ft
� qZD A 3� 32. Z� /� 10.DRILLINGLOG
LATITUDE 36 S3
` Z �� , / From To For atio Description
LONGITUDE �1 2— 0 6.). — tt/O. ? SO,'
Latitude/longitude source: 0 GPS 0 Topographic map / — /C.) ,472/- 56I -4 Lb.,: i-----
(location of well must be shown on a USGS topo map and /
Attached to this form if not using GPS) /U c 7 a e1Qck slccf e '6-5(t,!
4. WELL OWNER
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OWNER'S NAME 4 �n O / b - �60) � �����'
ST,�R TADDRESS 23oZ rJa /`{ C,-/2CR -
r/h e `] C-x /C it/c. g s-6G3
City or/own State Zip Code
72 302— 63 o6
Area code—Phone Number
5. WELL DETAILS: qOO 11.REMARKS:
A.TOTAL DEPTH:
B.DOES WELL REPLACE EXISTING WELL? YES ❑ NO 0 I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTION IN ACCORDANCE WITH
C.WATER LEVEL Below Top of Casing: 5 0 FT. 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS
(Use"+"if Above Top of Casing) BEE R VIDED THE LLOWN 2 �I
D.TOP OF CASING IS FT.Above Land Surface* � G% -oaL/ 2.,- 2 / ''2 4
*Topof casingterminated at/or below land surface may require SIGNATURE 0 CERTIFIED WELL CONTRACTOR DATE
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a variance in accordance with 15A NCAC 2C.011 . /Ail h , . AI .11 'N
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E.YIELD(gpm): �Z METHOD OF TEST _'e PRINTED AME OF PERSON CONSTRUCTING THE WELL