GW1--05012_Well Construction - GW1_20240828

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./ , '� �j� j� �L WELL CONSTRUCTION R
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:;`,;,:, fir. North Carolina Department of Environment and Natural Resources-Division of r Quality
�,�-V2, WELL CONTRACTOR CERTIFICATION
1.WEL111���ONTRACTOR: f. DISINFECTION:Type
Amount
0 �� / /��l�i Q�lf g. WATER ZONES(depth):
Q c� [r From a? To��G ( From To
Well ont/actor(I dividuat)EJame � /�A From To From TO
rf^ 4/ `1" -r "
�� ny 4 l From To From To
Well Contractor Company Name Thickness/
�� C� (�`-_1 i 7. CASING: }
STREET ADDRESS ! ! J , Dept lam er W fight / M serial f
// 3 I ` From TO Ft r I
�T r
Z"Code i From To F..
City of 7wn g��,�1L'a ^ 371� oye 1 From ;o Ft.
(2a( )- �CJ "- � ?
Area code- Phone number g. GROUT: Depth'�/� Material Method
2.'NELL INFORMATION: l From V To. 42=Ft. __
I From T o Ft._____—_ _______
l SITE WELL ID#(if applicable) O. I
TT I From To. Ft.----
WELL CONSTRUCTION PERMIT# C./ ( a Siot Size Material
OTHER ASSOCIATED FERMI T#(if appticabiej 9. SCREEN: Depth Diameter .n in it
{
3.WELL USE(Check Applicable Box): Residential Water Supply t From To To ct in in.
4 l ' From
DATE DRILLED /0 ^ To_Ft, _ ,i.:. in. ___
TIME `D AM e Ft:19 TIME CG(t�1PLET is
i I 10.SANDIGRAVEL PACK:
4.WELL LOCATI 'J: i Depthz Material '
Ft. /4llLj 9 S )fl,
CITE: 0 COUNT`. To
9 /r To
1 FL i4._,„
( trees Na, .Numbers,Communib ubdwSion,Lot No..Parcel,Zip Code) i T o —-c_
TOPOGRAPHIC!LAND SETTING:
i 11.DR:LLiNG LOG
i Slope Valley Flat Ridge ) Other Formation Description
1f (check appropriate box) m ay tie m, , I l j From To
LATITUDE __ 1 minutes tseconds or ; i I' , G�
111 1 in a decir a:-.rmat i 1
LONGITUDE- - - ' ��- is
Latitude!iongitude source: c GPS c Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS) i
s.WELL OWNER r
OWNER'S NAME .7;;1'1 0 ni.
STREET ADDRESS .. r
7
��
City or Town State Zip Code
( 1- 12. REMARKS:
Area code- Phone number
'�S
6.WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? ENOS 3 ' - 1 100--Rest Y THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCO" CONSTRUCTION STA. DARDS.AND THAT A COPY OF THIS
c. WATER LEVEL Below Top of Casing: - _ i RECO. i sF I PROVI 0 TO THEY_
Use"+"if Above Top of Casing) ���
d. TOP OF CASING IS 1 FT.Above Lard Surface' 1 E 0 CE IED'JJ=LL C�NTRP.C?OR DATE
'Top of casing terminated atior below land surface may require I Sr
a variance in accordance with 15A NCAC 2C4__A (f
, . 0e. YIELD rt1: METHOD OF TESh' i P INTE NAME OF PERSON C S,RUCTING THE WELL
I
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form G
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 568.