381745_Well Construction - GW1_20100318

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WELL Mg (Meet APPOOeble Box): Residentlel Water supply m'
DATs DI rus0 3- - to
TWE COMPLETED Z;00 AM O PM E
3. WELL LOCATION:
CRY:—WAtcltAeti
COUNTY-
TOPOGRAPHIC/
LAND BETTING:
(checkWiley CAMOOtMr
ePpaphve
IATITUDE .�...�.° ..._304 h,_
LON0RuDE.. O, I.320 (r )
Latitude/In ate: @%PS OTopo®aphic map
itcaSbnolNen nbe Mownan a USGS tope map and
Mhchadtotir Ian bpi u+hv GPS)
4 W .L owwm
OWNER'S NAME ►646Tt j4 i o
STREET ADDRESS 57104 M cwNoc
WA*t Ata L 2. 11;
a Steh Zip Code
�50G,-332.5
• roan mina.. �--��
4111 /; d.6/04(
3 11
North Caroline Department of Environment end Natural Resource.. Division of Water Quelhy
WELL CONTRACTOR CERTIFICATION N
1. WILL CONTRACTOR:
ilqAtAt 1E l LwEL
ems
STREET ADDRESS to(oW iht1 w,JP41.
(140,444 tiu lit
Or own fate zip Code
} �l0'1 �8oIN . •
nee 000e• n
L WELL II'BrMRMATION:
SWE WELL ro.(1,oporkoo o
STATE WELL P eppooep4)
DWQ or OTHER PERMIT 1(II appOCable)
S. WELL DETAILS:
a. TOTAL DIP*! 3o0'
b. DOES ILL REPLACE EXISTING WELL? YES p
Mey be In degrees,
minutes, mold, or
in a decimal Mont
NO Sf
o. WATER ISM So sTop d cuing: 3o .
• NN •*• 'Above Top of Casing) _--„_FT.
d TOP OF CASINO q ( FT. Above Lend Sorrow'Top d � W te—below lend eurtao, may require •
e vowrto0 h moccrOance vMh ISA NCAC TC .0116.
YIELD Wm): ...IL... METHOD OP TEST H'1Ry
.3002.
1. DISINFECTION: Type `1010 t}M Amount IC 03--•
0. WATER ZONES (depth):
From 45 T From 24 To��
From ("i0 To From 2 /; To
Fran I91 ToFrom To,_,�_
0, CASING: TltlobISsv
Fran•_ 0� Depth 844 Ft. (o r11" WW2. 1 MP tC
FranTo Ft.
From To
Ft
7.OROt)T: Depth
Fran • To 3 Ft.
From_. To 31 Ft.
From ToFt
0. SCREEN:
From
From
From
Depth
To
_ To_
To
Demeter OM Saes Mond
FI. In. h.
Ft. In. h,
Ft. In. M.
0. SAND/GRAVEL PACK:
Depth
Fran To Ft.,
Fran To Ft.
From To Ft..
10. DRILLING LOG
From To
0 (y
3— 11 .32
300
Sae Mork,
Fitmdtl peialptbn
lip Drp�'
o#I t:IrLr
(saw,. C4,1 fjarac
�Q,9rr=f
RF(EIV
11. REMARKS: i'L AR 1 8 2010
•uri-tat‘.on 'rxessingvnu
nr_
100 HERt1Y NAM THAT MO Will. WAS CONOT1a1CTED NA000IIOAIOI IMIN
ISA HCAC tC, Walt CQN$TRUC1ION $TAMOAROS. MO THAT A COPY OF TNN
RECORD ra/ PEEN MOWED TO THE WELL OWNER
SIG R 0 E
QRApKtL L. O1.w t
PRINTED NAME OF PERSON CONSTRUCTING TREWE .
Submit the original to the Division of Water Quality within 30 days, Attn: Information Mgt,
1017 MBA Oe,1/Ice Center- Raleigh, NC 27699.1517 Phone No. [phone] ext 665,
Fa ro 0li11,e
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