404107_Well Construction - GW1_20120402

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NAME (printi.a2:1
WELL C:CY. C0311 !:k;
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4I 1_ 0 7
ti Om) ?7,,,I.D9'85
ri[CATION# ;1.1 ?
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1- (Check App,' Box): Residential 1..:1 114.arLicipaYPublic J Indugrial 0 A ; : 0
M0111; ":: )3 Recovl, Heat Pump Water Injc z.-.1c,n 0 Other 0 H./Other. List Use
• • • I.
.ASSOCRAMi: 7'0 PERitalli
iffly .1 1:11.; cable )
2. WELL, i :;)
Near.) 3 !.• Z): jAdeti!!...!0,01 County tia 44) iti6 OPF
PIM') er S•COZ ,;, f L. E'llbdiviston, Lot No., Zip C:
3_ 01101 5-7- E
Add! _____ groo
(Stmet
L. -
Zip Code
AMD i;; it number
4_ DATJ `, !. LED .2:J
5. TOT.. 'TR: 91p4
6. De IE:E RE1)1.A..t.E. ;13-MG WELL? YES J :NO or
7. STA" P. TN Top of Casine:
(Um --+" if Above Too or :;1-.10s)
8_ TOP ( '2. I.r.-ffiNt"G IS 11:: FT_ Above Land sface
*T30, t.„.:*014101.0ttee Er.e7 .0'.11 land surface requires
; npw. I. :AC 2C .0118.
9. __40- erAE T.1.101) OF TEST4.Ce'. _
10. WA1',.. :.!.: .113:a (depti .1:
.11 AY •••
1 1. DIST]. i'.: iON: Typt _
12. CAS: w.!:......; Well 11,10,11. :is
i Divtb ,,, t Diameter or WeiglvdT., Material
Frono.71„._ To 0-1..0 ':'....s.,aSc..k I:I 4
Frorn........ ,.... To ... '. :.
Praia! To ..:i
13. GRC,Il )T Depth • Material
...
Froc...) 0.....„T© •ta 0 .71 ,A.,./10At e,
•....... .... •
Frerri To 71
14. SC:fl.! i?.......: Depth
Frorrl...1.. P. ..._ To.......r.,,.
Ffer1.
1 To .:',
,
.-
,.,.. ...--
in.
..........
is. SAN:r." .:?:1, :1/2 'VEL PAC: .';.;
Dityth Size Materi.:,t
Fro ttio To r; t
To _ :1;!,..,
AftiOtUlt
•••___
1•
•,
iktetilod
16. RSN-', •
1):!imueter Slot Size Material
.1 yyjn. 0 /6 in. A) e-
Z-f
'NOV • ..Wie •.••••••4
01.0.114001
•0.0..1
dinism......140.V., MA • I. ••••••
Mpographicibi:A. setting
C.1Ridge OSlope E'. 1:811.ey mat
(check appropr : t es)
Latitude/longitude vi..211 location
(degfeesintismit;;. :74;iid.$)
Latit§:.sn/longitude source:OC:..PV.71Topographic map
r:* iinx)
Fror To
A a
400 - 3
g
••••••••••••NW.I....,NP.W.
LOCATION
Shov: .direction and distance miles from at leas
two ri Roads or County EcAds, include the road
nunatacs, and common rood ray.
a We"
° *
eitAro,..K"
I . .
141.Thrri-,OG
foarttion Description
Ws* 0.0••I
I DO HEEL 1: ,1:11.T.TY :1 WELL WAS CONSTh. .1(TED IN ACCORDANCE WITH ISA NCAt. `..VEL By
CONSTIZII STAN)/ ..; THAT A PY Ork"7...17,13 RE 'IP KAS E.' :iq PROVIDED TO TF: 0
TRUCT1
StibinOltji to tlth6 a11 Or Water Quality,,
Raileiti, 733-7015, vv4tb;),70 ;.:if.) day&
RECEIVED 03-26-'112 14:49 FROM- 9103133102
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Efion1ko:,,-;agemmeat, 11617 IWii Cester
.grtrITM
APR 0 2 2012
1.1 T
MAR 2 7 2012
forrnation PTOCeS8iF0 Uni
)010./P, G P004/011
TO- NC DENE P&S
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