GW1--06879_Well Construction - GW1_20241118

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1 . t..,,u.. e . , ResiDENTia, WELL,covirruct iota RESOFtl) •
i:' North Cerolins Department or Environment ene Newts;Resources-Division of‘krter Quality .
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WELL.CONTRACTOR CERTIFICATION 0 loge... .c..cd, .
I-WILL CONTRACTOR: .
1. CRIMINFICTION:Tyner/1 isc./el P;./) AllICNIM /6
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‘774)r e:_1_ 1-Z c l_& ' • II. WATER ZONES OWN'
Wek Contractor(liscinsduall•Nr pram gal From' To
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Wok Conn Company Name Froor TO Fiom To ,
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ST RncET ADDRESS '..352 177C0 4 A#2 Xia .$. CUING: .
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Stale Zip Code From , To • •' Ft.
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• a.WELL INFORMATION: . -
frarit,,,,,S_T ut Ft.6,9„,770,,,.47 /241
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• WTI WELL ID Skil ocaticeotet . From To _ Ft.
STATE 01E1.1 PERMIT**sopeeelkel 471-d.9%$A t .From ,To, Ft.
OWQ or OTHER PERMIT,0(it applicable) . S. Sauget' Dew
DrINIMar Skit Sin' SAWN
Fool To • ft. in. En..
WELL USE(Cheek Applicable Ikei).' R1440(411 WON Supra!
lifeel • To in ft. in.
DATE Dom= /0 -.,g - a se) ‘ ROM 'To tTTr. Iii in.
TOSE COMPLETED/0• a:s -cl er WA( Foke b
A SANCVANAVEL PACK:
Z.WELL LOCATION: Dell
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COUNTY./LZazatlz„ . __.
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,,s_se "..-rofries Cij From • To_ Ft.
,Strete Name.wooers.Cenenunity,Se, reel. * ) „
TOPOGRAPHIC/LAND SETTING' .It DRILLING LOG . •.-
OSiose,OW*/ OFIN CMOs ("Other - ROM- To FarrnattOrt DOmnpeon • ..
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LATITUDE 3-.P /6' gt5eg. mineseL Nemo sr . • .. - . • - -.'
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LOnroiTUDE 713 /01 , ,0.5"›
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Latitude/longitude source: iirOPE CTopovephic map . .
(icalkin of sal Mini be Omen on a USG!tom moo one . .
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aftschri So this Awn 1 not Wiry OPS) •••••••••••••••SOmm• '''.
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STREET ADORES!35 C , L . • - _ ,,N 0 v I s 2024 • ••
Vithk4,19
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Area make- Phone number • . ••• ••
. , ' • , II. REMARKS: . . • . _, ' '
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E.WELL DETAILS:
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s. TOTAL DEPTH: . _ . . S.
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b. DOES WELL REPLACE EXISTING WELI.t. YES D HCliz(•
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I DO WOW Ceelerr IwA7 TWO WELl WAS COwiTeuCTIC od ACCOODAPICI witm . .. .
e. *ATER LEVEL Soon Too ar Comm. .3 0 ' FT. • -19A+CAC VC. I.COMYeuCTICW PAM:AA .C4 AND TNAT A
Ns. .•it Above TOO Cd CIMINO• 'MCCORD Poke Pi PNOVIVED To tyre*um crenate ,ccc"cc 714%
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cl• TOP OF CASON)IS, -.t_ FT Apri.Lim&owe' - / .
°Too ill awns toriensted sties beton tend stem may Ravin • ' ,..--I---4-tit> ?;•-51 /0 ..`.J..f--.25" , . '', .•"-.1
E OF SERTIFI 0 WELL C NTRAC'TO0 DATE
variance m bccettlententin ISA NCAC 2C:01 ie. -.
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. yilwan L0 t) D •NETHCO OF TESTak“.) ceiiii.i>,,
. , PRINTED NAME Of PERSON,CONSTRuCTiNG THE WELL ... _
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• Submit the original to the Division of Water Quality withlo 30 day*, Attn:infOnnation Mgt., • ....
i bil 7 Mall Saireleo Cantor-lialtarlp.NC vsti-isit _Rime No.(01111)-733.71711 eat NIL I nee.Mb
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