GW1--06941_Well Construction - GW1_20241119

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r NONRESIDENTIAL WELL CONSTRUCTION RECORD
}dl c- North Carolina Department of Environment and Natural Resources-Division of Water Quality
. oo WELL CONTRACTOR CERTIFICATION# Qq VS
1.WELL CONTRACTOR,;_-- 2 .` d. TOP OF CASING IS ( I ' FT.Above Land Surface*
J elt'Y / a - 'Top of casing terminated{'aUor below land surface may require
Well Coctor(Individual)� Nam a variance in-accordance with 15A NCAC 2C.0118. /
1--)�V'/ &fAL.- tut'l-C- 1!/f'(CC t.''tc� 0
Well,�Contractorbempany Name J e. YIELD(gpm): �� METHOD OF TEST ��d�.f W
J.5 2 /11 Occ.L-f"Cy n 4'" f. DISINFECTION:Typed -1 O rYI16 Amount c:›1 5er O 2
Street Address g. WATER ZONES(depth): •
r D lAL 1 5 4 ut W "I C Top ?A Bottom.S-'6 A YI Top Bottom -
City or Town-` State Zip Code Top icy Bottom?G/o t-A Top Bottom
('o f�) ' '7 6- 9f 4/4 T Top Bottom Top Bottom
Area code Phone number Thickness/ •
2.WELL INFORMATION: 7. CASING: Depth Diameter Weight Material
r 7`WELL CONSTRUCTION PERMIT# / 3.,5---e D Top )'/ Bottom Ft. ' ' -5-LW( /51IJC
OTHER ASSO,CIATED PERMIT#(if applicable) • Top Bottom Ft. .
SITE WELL ID#(if applicable) Top Bottom Ft.
3.WELL USE(Check One Box)Monitoring❑ Municipal/Public/ 8. GROUT: Depth ,, Material Method
Industrial/Commercial❑ Agricultural❑ Recovery❑ Injection❑ Top 1-. Bottom Ft.
Irrigation❑ Other 0 (list use) u h get 7— C'A►1`t'(4,' Top •' Bottom Ft. i"'�-:.}:k, ,....' -•= =r a._.
ADATE DRILLED id- i a 'it Top Bottom Ft. NOV i J 2024
4.WELL LOCATION: 9. SCREEN: Depth Diameter Slot Size Material
/575-7 G, y ij Let kr Top Bottom Ft. ih. :-in; '
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,l,Zip Code) Top Bottom ' Ft.I in. iu in.
V
CITY: COUNTY CI 4 LP Top ?Bottom Ft.' , in. in. .
TOPOGRAPHIC/LAND SETTING: (check appropriate box) r • `'` I
0 Slope ❑ValleydFlatt 0 Ridge 0 Other 10.SAND/GRAVEL PACK: j ' ,
LATITUDE 36 Ifo, /6 71'DMS OR 3x.xxxxxxxxx DD Depth Size �` Material
Top Bottom Ftl'_
LONGITUDE 7 D ° ?6 r'n DMS OR 7x.xxxxxxxxx DD Top Bottom Ft. •'s
Latitude/longitude source: APS ['Topographic map Top Bottom Ft.'
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) • 11. DRILLING LOG
5.FACILITY(Name of the business where the well is located.) Top Bottom Formation.Description
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'Sp polls Aln.�5 rJeYI u45' /
Facility Na a Facility ID#(if applicable) / .
Street Address J .. / 5 7f ' e_... C....c/)
AZ e xi ale(IS o n NC .c--4 I yfa _e C-° CD u^of,-1 17F, .
City or Town L
State Zip Code /
�p k vl A J i D .1.,.1 r0...-,s l
Contact Name / -
/..-C 7 L „y ii ba4 L n / - ,
Mailing Address /
f-/P h derCb 'NC— I I . .
City or Town State Zip Code
12.REMARKS:
( Vic() 474.36 - (717'73
Area code Phone number
6.WELL DETAILS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
a. TOTAL DEPTH: Y.� J RECORD HAS EEN PROVIDED TO THE;WELL 0 /R. •
b. DOES WELL REPLACE EXISTING WELL? YES❑' NO 1p �� C ' ��` �- S�
SI N RE OF C TIFIED WELL C NTRACTOR DATE
c. WATER LEVEL Below Top of Casing: FT. � (0//' /j Lr a_
(Use"+"if Above Top of Casing) PRINTED NAME OF—PERSON CONSTRUCTING THE WELL
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1 • ---'-._._, . ,,..__..r� _ _0 - r,•_ .-. V Fr -_- .r._-.-I Form GW-1b
• r•Submit the original to the DIvisIon of Water Quality;within:30 days. Attn:Information Mgt:, 1 Rev.11/08
1617 Mail'Service Center—Raleigh,NC 27699 1617' Phone No.[phone] - . ,
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