GW1--04615_Well Construction - GW1_20240809

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• - North Caroline Depduned of Environment and Nalaial aeooiab-Diriaioa of Water Quoit/ -
- WELL CONTRACTOR-C> ICATION 0 4119-A [ • 1
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WON CQrrtaryo►(tndMidrdq Nana h Q To.1 5 Fun To-
Midtael G.S e F To Rom To
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•TADDRE,SS 204 Tom Ave - 7. MOW
/- . ihicIr read - _ _
Castle-Heyhe - NC _ 28429 _ From, 0 D OD R. DkrarL mo mid- .
- T 1y or Timm Stab 71p Cods F�. --To FL
(910 4_231.6669- Fron1 To FA 9 i, t JL
Area coos- Phone number
L.WELL iAMOW - - S. GROUT: Depth Mieoal Method.
Rom 0 To _ a1 i e .
SITE waLDs�appioeEie rr"jj f From To R,. T T -
�L CONSTRUCi.ION PEIWITI 'i- 004 From To . - Pt. - -
oniER ASSOCIATED PE10171 itmoo a • - .9. SCRE01:: llepfh 9 �s ,�!
3.WELL usg(Clredr ' Bosh: Residential Water Supply I.� -Franij_To you ia. t( b.. t'U C _ : .
- DATE DRILLED — - m -, 1$ FL_ in.
TIME CC PLETED AM} ( PM) Fro From To _ __b.Ft, ill- in._ _ .
- &WELL LOCATION:, / 10.SAI RAVEL PACK: ,f s
any: €.-o i I foNounrYNJ e oo From Orme To FL Sile qk i'l��4:.' `�'-�sd ir(
A. Gca M _4- et i ' - From To y Barra Numbers.or b. From To A. "'�� v 9 2-024 -
113POG!1APHIC/LAND SErnmec 1T,•;.: :,.::'<; ? r: ¢' a A i.*I'
f Slope I Vaiey "f FLt .1 Ridge f Other . .
(cheeksPp wsori 11.ORt.LMIG LOG - DI VC.,,,3C-ua
May LATft11DE __ be is dogma. From To - Formation Desaiptlpo -. -• -
mimes,lemmas or
LOIIigtuot ___ ._ eradoodad forms • D-35 5A tV-D . -
• Lalitaddtoog'ibiclamu et: f CiPS I Topographic map' - 35•- bO C LAB- • -
(bsaBon of reef must be shown on a USES amo mop and fX�-- CV) I 5n T - Kt�C i�
_ .a(hdred b lhia form Virotu.Irg GPS)
LNELLOWNER 1OD• [35 Li t . ,sronlg
oWrurs tow hi-- in a F-¢�j' : .f, g Map
trREET ADDRESS I i G- L D
l i VC 0- u . t. PQ "-SAO6 SCONE -
orTawm "Seale Zip - -
ol` a3I-1350
oo - n . , >�. REMARKS: Qe
It a. TOTAL DEPTH; ,OO e_SS�ce_ g�[Y�.►r t.j l r - 60'-Sr,
- b► DOE+'.WELt';.I MUM YES, NOI rnot lff iTFYTfMT1HS WELL Veit co116Ynumsosesocontremsvans -
a MATEY LEVEL Bebw Top of Cadmr s ooraraucmaa sr �uatw►TwoaPraF�rrt
. (Clse'+'N Above Top of G's�Mr@l
d TOP OF CaAsif61s + Ft Above Land SueTas' l ----CONTRACTOR- -'fop of ea#ine terminated afdor baba lend stale*may require K;NA _ OsajOtl-- -
d mrianoe h boomers*with 15A NC�AC-NC.0118. p ` Michael-C.Stage -
..YIE.D{spnx ri METHOD CP TESTA i i 'i T T' PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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- -Subunit the ef1ghuil b the Division of Wabsk- wain 30ti ys. Atfn:inforgrauon Mgt., - orr.,,,;PS..
161T Ya98Mvice Center—99110011.10C 2788E-41117 Phooe No.($19)733-7'e110 eci r«-_