382802_Well Construction - GW1_20100427

1. WILL COMMOTION:
T1tANWE L, Ot,w fZ
Wsil Conlrarda (YtdlNduil) Name
eAsiloi,t
1-16
I recta rCcmpsny Nemi u t
RESIDENTIAL WELL CONSTRUCTION IZCORD 3 2 8 0 2
North Caroline Department of Environment and Natant Resources. Division of Wear Qualhy
WELL CONTRACTOR CERTIFICATION N 300ZA
STREET ADDRESS (olnl' ME1 t4 (,
mo o • 1,1c.
Clly or Ulan State
7te4-Boss
AIMS► h
L WELL INFORMATION.
SITE WELL ID FReccort,01i)
STATI WELL PEI:MITED/appliable)
DWI', OTHER PERMIT Nor appoceble)
28tt2
Zip Code
to-,8
• WILL IAE Medi Applicable Cox): Rasldentlal Water supply
t7IATEWOLLID I4-,O
TM COMPLETED3 ; 30
a. WILL LOCATION:
CnY: MRS►IVILLir
I/123 AuSo.+vlt.uE
TOPOGRAPHIC/ IMO SETTINO:
Moak�� �� GOtlter
trPpav I*
LAB .+ . 5 0 03 090
LONGmTt1DE 8 moo° 201 qp-�..
Lati o source:flPS OTopognphic map
• �oo(blraaal,lpgpa*him an. f/MGS topo mop and
allotted to hit !MI not why GPS)
4 WEII OFIWOR
OWNER'S NAME
STREET ACORE83
%owcoRt.
Am PM('
COUNTY UPtoo
May be In agrees,
minutes, wounds or
Ina *mime! ibmat
Arc.
�ryaTown • • State Zip Code
tom0000ddoa„}
�� one
2So Z7
aw�MAIM
L TOTAL DEPnt 2 50
b. DQ8I WILL REPLACE I MMTINO WELL? YES D
0, WATER LEVEL NOW Tap of Casing: 30
(Uwe W Abor. Top al Casino)
T4iP OF CAtRNO II 1 FT. Abor Lund Swine'
?op d css utftr bs OIM lend suAecs may MINIM
ev rinooh Kcadono• Wth 16A NCAC 2C .0110.
YIRD (W>rtlr �.. METHOD Or TEST AA
NO I'
FT.
NO
I. DISINFECTION: Type -10010 Apt Amount
0. WATER ZONES (depth):
FromT
Fran ,iro ' To_.____
From 2.15' To
S. CASINO:
Depth
From D To Lilo
From To
From To
FromFrom
From To
Thblotwv
Dlemeter W.aItpNht Malarial
F1., S_R 21 P✓c
8 oz.
To
To
Ft.
Ft.
7. GROW: Depth Materiel MtAhoO
FesTo 3 Ft. PoR�rr+NA 1-ouR
Fran+ To 35f FI. .1412oN a7� Pub, —
FromTo Ft.
0. SCREEN: Depth
From To_
FromTo_
From To
Otwnoter Slot etas MOW
FI. In. h.
Ft. In. tn.
Ft. In. h,
L SANOIORAVEI PACK:
Depth
From To Ft.,
Fran
To�� Ft.,
To Ft..
10. DRILLING L00
From To
0 -7o
-1O 90
90 ZSo
$Inu MINIM
Formation Dsaallptbn
QRa.,,J A2r
g0 & E 5A•rE
[ r �E Si arE I K
11. REMARKS: APR 2 7
2010
►„s _
CC WRIST CIRTvf TINT 1100 WILL WAS CCNS11M,CTIO NA000ROANCI IM@I
11A NCIIC M. WILL 00IIST11 J0'IIDN STMIOAROS. MOM! A COPY of 11M
RECORD ME MN P OY010 TO THE WILL OWNER
gl1 Al gi g L. Ott veg.-
PRINTED NAME OF PERSON CONS'rRI.VIN FORTEUL
8ubmh the MOM to the Division of Water QuaIfty within 30 days. Attn: information Mgt,
1$17 Ile Sonia - RSINgh, NC 27449.1517 Phone No. (S19) 7334016.xt 666,
•
Ftrmi glop
Rey. 7 06