GW1--04510_Well Construction - GW1_20240730

_ ;,,ESTAT"�'N'. RESIDENTIAL WELL CONSTRUCTION RECORD
��JJ �� PZt,
Zi
•~ `'' North Carolina Department of Environment and Natural Resources-Division of Water Quality
,V • I-� O:
" , r ,- WELL CONTRACTOR CERTIFICATION # 3`3 k I.
1. LL CONTRACT R: F.DISINFECTION: Type: C &t I NQ Amount / O-6In (OW) ✓V nQ_ 1/1\e- A, )// D G.WATER ZONES(depth): t
Well Contractor(Inc ividual) e I From / ( To i pf _ From To
�' P(A1,vA---e� i a/ 1 i) (� From To _ From To
Well Contractor Com.any Na e )L f From To From To
ST ETADDRESS w,`. y) 3 w"4 L pi iv� ,� 6. CASING: Thickness/
C6t,? -r� A 9y 3'3 Depth piameter Weight Material
City or Vown „Stale / Zip Co From 0 To f7ZFt /S �-'/• P 0
V7 �3 � 9Sf�i � From To — Ft
Area code—Phone Number From To Ft
7. GROUT:
2. WELL INFORMATION: Depth e^ I Material pMetho
SITE WELL ID#(if applicable) d
I From 0 To Ft Q-A0i ��
STATE WELL PERMIT#(if applicable) 3 6 9 3 oil —
From To _ Ft
DWQ or OTHER PERMIT#(if applicable)
From To _ Ft
WELL USE(Check Applicable Box);Residential Water Supply❑ 8. SCREEN:
DATE DRILLED Depth Diameter Slot Size Material
TIME COMPLETED 5 - Z 3— 2-3 AM❑ PM[' From To Ft in. in.
3. WELL LOCATION:fly I CL 'VC.a�Z3 From To Ft in. in.
F.
G-
�� r l l From To Ft in. in.
CITY; `p-i d 4-- A{ I� COUNTYr l 1°�J YEAn g. SAND/GRAVEL PACK:
I-+�SOC cAtivt i V 131UC.�j e• S Depth E$i`e:+; Ma�rfaT'
(Street Name,Numbers,Community,Subdivision,Lot No.Panel,Zip Code) l ..,.•- JJ f1" r"
From To _ Ft
TOPOGRAPHI /LANDSETTING: From To Ft JUL 3 0 2024
❑Slope alley ❑Flat ❑Ridge ❑Other
(Check appropriate box) From To _ Ft(AC..;:nrs. r.-,.'.{^ ,4 tio-k
LATITUDE 31,..livi,ii 360 9 66 fit)! 10.DRILLING LOGFrom O Formation Description
LONGITUDE Yjo,`1' Q 0' 0 / 420,„, h/Tb ' S D )/
Latitude/longitude source: GPS 0 Topographic map '
/ I 2p
Ai. C �'(location of well must be shown on a USGS topo map and
Attached to this form if not using GPS) -r- / 70/ A P ° C/'
IT
/70 - /71? ' A)k, c "o ( 16-, Mr.,,
4. WELL OWNER 22 Ir
OWNER'S NAME C 6-c LW �►�' ,�14►1(ll0G,�P1
STREET ADDRESS 3 T Z /V lC D5/eM ' n--
Pano 5 vc /_t.i c fi� 3V 5T3
City or Town State Zip Code
77d 1,07 /5s)-__
Area code—Phone Number
5. WELL DETAILS: I 11.REMARKS:
A.TOTAL DEPTH:
B.DOES WELL REPLACE EXISTING WELL? YES 0 NO
C.WATER LEVEL Below Top of Casing: / I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTION IN ACCORDANCE WITH
FT. 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS
(Use"+"if Above Top of Casing) BEEN P OVIDED TO THE WELL OWNER.
D.TOP OF CASING IS FT.Above Land Surface* Flu Z f Z
*Top of casing terminated at/or below land surface may require SIG TURE F CERTIFIED WELL CONTRACIIi
• DATE/
a variance in accordance with 15A NCAC 2C.0�148. . l " � !'C " t D N
E.YIELD(gpm): L O METHOD OF TEST " /4_ PRINTED NAME OF PERSON CONSTRUCTING THE WELL