385300_Well Construction - GW1_20100719

RESIDENTIAL WELL CON$TRVcnON RECORD
Notth Carolina Department of Environment and Motors! Resources. DIvIsion of Water Quefhy
WELL CONTRACTOR CERTIFICATION N
1. WILL OCNTRACTORt
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Name
t`K. 11.t.1�G
Name
BTREETADonne '� (Ylfuo.Iv1_
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WELL INFORMATION:
MIT! WELL ID ti(SeppSeek1e)
DATE 0101.LND to
TIME COMPLETE, I 100
S. Pau. LOCATIONt
CITY:w'OT COUNTY tinEuu.F 4 & 6
T37-05C4444 1, (to PG #11
ITATII WELL _Pp_o_We)
DWQ et OTHER PERMIT 0(p eppSC ) 1030 4I Ql
WILL WI (Cheep ApplkabM Boxy ftof Venn,. Water Soppy 61/
TOPOp 55I LAND SETTING:
Meek WW1* kV
%Arnim .+L ' 0.957v
LONO/TUDB p 35L
lattoknonsitode Kw,: BOPS O Topognph(c mIp
lb:46WaNmusra shown on. uses fop nap Ind
411040 btit Amn'no( uthp ORS)
weal NAN! S-rt-
STRELT ADDRESS IS Zo 5 C ee
CAAmarce Y G ZS �z
�, ,a v1IIl tab Zip
tiro j• atrn K
WILL DIMS:
a TOTAL OMR 515
a Don wou,IRK** luotTnry WILL? YE5 O NO Ge
WATER LtVll abecv 0 Casing: 30
AMO PM@f
NN'.' IA ATop d Cosines) FT
d. TVP OP CASa"O p FT, Abo701 Lind Suii,'
'Topcinsto Stlor bred surfood they nquko
• torlonoth Kattencetsith 16A NCAC 2C ,0110.
.. Y1110 =f.... METHOD Of TEST '
Owns,M.y be In Owns,
mown
In a dsofinel Pam1
3004A
35300
1. DISINFECTION: Type 10't. 14114 Anent 4 C4 ,
S. WATER ZONIS (depth)
From 495 To from To
Frorn1_7o�w From TtL.��,
I.
From To From
0. CASINO:
From0
From
'torn
Toh4S Ft to`x",
To Ft
To.
7.OROVT: Depth
Fran To 3
From 3 To 2.0+
Fran To
I. SCREEN: Depth
From To
From To
From To
tr. SANINGRAyEL PACK:
Depth
From To
From To
From To
10, DRILLING LOG
From To
0 4
Zt
11, REMARKS:
Ft
To
Thicken/
WsMOM4 MOM
SD 2t V�
Mrtterfel
,Ft. P
BEN b, ,11
Ft.
Ff
Ofwnotor Blot Size MOM
FI In. In.
Ft In, 11.
Ft H, In.
Ft.
Ft.
Ft.
Stu World
'gen Gam,
&Lows D‘RrlQoc.:c
ZAIJ%TE
11-0k-6:r:—B`l1—I. 9.
JUL 1 9 2010
Information Processing Unit
DW(.1/16U(..
100 NERWY CORM THAT DO WELL WAS Co1011KIC11D RAW:SOA I0S VCR
1 to NCAC 19. WtL L Cot1STRuat10t/ STANDARDS. MO 1W.T A oOFI OF EISMAD ItAt $UP4 MtoVlotD To THt WtU afoot
re". 0.* L. ou.40-
RNT D EOF R8
Submit
�� to the Division of Water Quality within 30 days. Attn: Information Mgt,
Ionia - Raleigh, NC 27590.1017 Phone No, [phone] .xt 656,
For INAS
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