HomeMy WebLinkAboutGW1--04613_Well Construction - GW1_20240809 --- • .IM .. . . - . .
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North Carolina Department of Environment sod NalurafRomorces-Division of Water Quality •. -
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WELL CONTRACTOR-CICEMFICATION#13-111-A
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1:Ma/coarntAcvow ' t. esmarectiosei*pii jo jlaississat.
-Sage Ming and Pump Services Ile. .
- vaunt hantul(dobil*
Wel Contactor(Inclividoel)Name ., - .. , - . F I 48 -To, \Q n. From - To
Michael C.Sage . V - Fronk To - From To _
Wall Costrackor Company Name .
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4 ilimr AppREas 204 Tom Ave . 7 V
ibidameal ' - -
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Castel-twineFarm A J. To -kl-klp R. .
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.(910 4_231-6669- . . From C) To6 ) Ft FL---(; C.1)46 -
Area corn- Phone number
2.twat INFORIATIOlk: - - I. GROUT: Mph Maimial _. . likoll.
ME WELL ID StivrollotdoL,—....,____. .-. Fmm_9= To_3___Filltnialle. W_, -
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idol cOtiampariptt PERIM WP - 1-k- o()ks- Froat To . . Pt.
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- ODER ASSOCIATED PEWITS('molloble), • _.
---:- ,11. SCREEN:- Depas , Diame SkA She - Niatudal
. 3.EMIL USE(Cite&Ainolloable Boa): Residuals,Water Supply'. -FrOm-ILI 6 To l‘i0 Ft, a kr. I(1 In. Air • .
' DATE DIEU.ED '-a3-1-.:;)A-Q LI •- ...._-bi• -- In• . ..
TIMECOMPLEr.ED. a7t6i201;G%co PAO Ca - mom - To Ftt. h.
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4.111E4 LOCAPOW ' 10.SANNEGRAVS.PACK:. .
CTTY: ai'i\M ii\ -NrOf\ - COUNTY. -Pe4.) Haft0t4 Deplb - She -Material • _ •
From- To .. FL - :.
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- (Streatlimar.Numban.Coramarly.Suivivirkei.Lot Pb..No..Parcel,Zip Cods) Fiak C To _
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TOPOGRAPHIC/LAND SETTING: .
. I Slope 1 Veiny *I Flat 1 Ridge I Other
. (Cheek sIPPKVAllb a* ... 11.DRu.ING LaG
Maybe is degrees. . From To - Formation Deacniallort , --
LATRUCE _ mingles.swan&or
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LOOGMXIE — _ in a&sisal forma -
0 — 5' • CA&Y el-• 5AiNd - -
'" • Lalinadthoogilude sooroe: I UPS I Topographic map' - • -
pocelon of wed must be shown on a USGS typo nwp and ' - 65 -'S-AAI p •
_ .allacireil to this loan t not using GAS)
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I.VIIELL OWNER h , .
OWNERS NAME Dibb\ la() . A\bC_.\-)---1--- . .rio •Ku0 RoCK' - "
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b-FREET ADDRESS .; 1_Li -\./-• c.
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Olti or own '•ouwa .. - ZI.Cods - V • - -
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b. DOES.INELL REPLACE MOPING INEU.? CZ ROI I DO HEREBY CIERTIFY TlisT MS WU.sitie 0011111RUCESD IN ACOORLIANCE WM
15A1CPC 3IC.raw_coenneucnota STAMARDB.AND 7HAT A COPY Orlin
TER LEVEL Elebn Top ot Casimir - 1 :
i_ o. WA (ustr+.wftJiowe Top pr. .FT. . nnoorm •ina PAM .,IIMIIE WIELL OWNER - .
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cii,..-4. - - 3:-6' 3-Li •
-_ d. TOP OF CASING1S- 1 -1.. FT:Above Lisiri Surfacer ' - k
- - -'gal)at-Caine tarmineled attar below had.eridace may mole IGNik OF C9NTRACTOR - DATE• '
a variance- in bccordarice wilt 15A NCAD 2C.0118.
. MichaeiG.Sage -
46 yiewsp* 1 0 0,'. mune alt TnoTA-i 1 r_ li 4--i- PRINTED NAME OF PERSON CONSTRUCTING lliE RELT-
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tioloadt the oilginil to the Division ot Ithdet-Quility within 30-days. Atfa:inhumation Mak -
1617 limit Service Center--Ra3111111.3IC 2701E4111T Phone No.411191 733-7210 eau c,__