404104_Well Construction - GW1_20120402

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WELL ‘r:r.. 7iQt (INifitirc 7i. 1 ' NAME (print) A4P C2.11 tZlIEriCA'FITON
WELLc: 1::Ii`cNI 'COW A: ;"..! ) 1 : PROM 6 r 29.5"./9',Fvk?
STATE se. 011:31TRICT! AssocEATED•WQ PERIOD;
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I , 'EL . (Check .;.• Box); Residential 1 jiiiunkipal/Public r."..; Industrial 0 ilL,F'....ri;:amA 0
Moqi( 3 • 1.? Rex Heat Pump Water ci Other p :father. List
2. WEL
Neer. sclWeet County4z4.1)
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i•hunbans, Con At....:: : i. Bubdonsion, Lot No., Zip C,: le) Latitude/longitude c I ....u111 location
3. OWN '.'. :4 1944or 1,42 4 14- (ciesrashninati .:::::;;;;t1s1
Latit3:Olongitude sourec:CI.7..K!: CITopograpbie map
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6. DO! 'YELL. 11.Z.EPLACE ::7.r..18TING WELL? YES: i.:1 NO er
7. STA1 '.:V? AT:ER LEV:?,'!,, ..'1. P. lax Top of Casine: _ ...r.. FT.
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8. TOP I i . .',',;( is,:T.f).‘TG IS I: !. ___ FT. Abon Lane. ;',: re'lcc4`
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11. DISTI% i .::: 1:* '.1(014: TyptL_.
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12. CASi: .f.?.. • Wall Thickro:ss
)eptIi. X.:iiarneter ar WeigIvit:., Material
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14. SCR,F, F...i.; Depth ;)!Erneter Slot Size Material
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LOCATIQ)sl SQfl
rection old distance i!.1'.1 Ales from at lc=
two S1'31:e Roads or County :11.f. ad; include the mbd
number.; and common road r
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Kif; WELL WAS CONFER:it:TED IN ACCORD !ECE WITH 15A NCAC WELL.
CONST,) S"TANDA3i,E ri;;,',L) THAT A corf •? RECO.RD HAS C.; EP.T PROVIDED TO TR (YWNER
Ave 13
J.Nik0 017 ',',NISTRUCTING to..15.
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Submiit irs CO traie )1',Y,;* of Water Quality,f 4'17 :1; lli
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Ralegh, ;,-11637, i9733-'70115o withil4.1 1:4 ,,111213,,s.
RECEIVED 03-26-'12 14:49 FROM- 9103133102
rrazdotp N.:1grageliDellt, 1617 Mal %ice Ccoaer.
APR 0 2 2012
CV-1 REV. 09/2004
RECEF
MAR 2 7 2012
TO- NC DENR P&S 4-ifom-tati9r) ig; - 'viclunv