~ PM ~ r OJ 1/ '+f NORTH CAROLINA DEPARTMENT OF WATER AND AIR RESOURCES

DIVISION OF GROUND WATER BOX 9392 - RALEIGH, N. C. / __ r/'(/ /{ __ :1 UM - -l-fo7 /V y~

Oril I ing Contractor ~ . ~ tfr-. Reg. No. Well Permit No.

I.Town~~~ · County CGM11,-~~.,.4---.r-----2. ---------------------- Quadrangle No. __________ _

3. Owner

4-. slope, hilltop,

5. Use of Well ----__ Date Completed ______ _

6. Rig type or method - ______ Total Depth 28 L. 7. Casing: Depth

From to ___ ft. ___ in. _________ _

8. Grout: Depth Material Method From ___ to ___ ft. __ _

9. Screen: Depth Diam. Type and opening

From to ft. in.

II. Water Zones (depth)

12. Static Water Level: ft. above top of casing below which is ft. above I and su rface. Date _____________________ __

13. Yield (gpm) Method of testing ________ _

\4-. Pumping Water Level: ft. after ______ h,rs.

at gpm.

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(place this sheet oyer correct square on map, match corners and circle a dot at well location.)

10. Permanent Pump:

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Installed- Date _______ _ By _________________________ ~

Type ______ Make _______ -.:....

Capacity ___ (gpm) Hp. ____ _ Intake depth __________ _

Airline depth _________ _

15. Water Qual ity Temperature (OF) __________ _ 16. We 11 steril i zat i on method _____________ --..:;._--,,--______________ _

17. Remarks:

I do hereby certify that this well record is true and exact.

SIGNATURE OF CONTRACTOR OR AGENT

White copy - Department of Water & Air Resources; Blue-Drillers copy; Green-Owner's copy.

Form GW-I

, DR I LLI HG LOG

Depth Depth From To Formation From To Formation

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LOCATION: Draw sketch below showing location of well in relation to nearby towns, roads, and streams with Horth in the direction of the arrow. Show distance from well to least two nearby reference points, such as road junctions, stream crossings or other land marks.~

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