383437_Well Construction - GW1_20100513

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RESIDENTIAL WELL CONSTRUCTION RECORD 3 3
North Carolina Department 0/Environment and Natural Resources- Division or Water Qualhy
WELL CONTRACTOR CBRTIFTCATI
�. tilro.L acurawarole:
cRgawE L_atve2
Wd Cantrecta ( )hems
will Ls) ELA.
yNW" Da-hun,+e
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oNt2oE cr 28112.
a Of, , = tat. Ip Code
"lost '7bK- 8085 .
offer
IL WELL INFORMATION:
an a wE t. ro •RePdoeale)��
STATE WELL PERMITIPor.pp_doo)
DWQ ',OTHER PERM POI appncabie)
WILL 1MB ((Astir AWN Ste: ReslOontlot moor Supply D
14414GAT,op o L-4
AM D PM ties'
RATIO .LID Li- 2-
TIME COMFtETED to 3o
7, WELL LOCATION:
ct1Yc (3Axi4A,,,
LA)cob► - 14
COUNTY 1lh o?
20
TOPOp/LAND SETTING:
Cafop'.OV,► Sint ORION COthor
Moat
LATITUDE .jLLatiludal
on a s o: dGPS D Topographic miP
( wittlalatrntustt r shown ay a VSGS topo m p and
MadNdto knit Rot ughp GAS)
4 WELL OWNER
°w n NAN AN1utrq, Do G
STREET ADORES; 3019 Cow1r (404 G.
231-13
�711►IS Oat , tate 20
,% 843-(0835
5,WILL
DM*
1
a, TOTAL DEI L...3`iO
a DOIS WELL WW1 IDOSTINO MILL? YEE D
May be In deems,
minutes, seconds or
Ins decimal Mnrt
NO Ef
a WATER LEVEL Salmw Top a Clop:
PO'1 thane Top d Casino) 30 FT.
d. TOPCF CAMS p i FT, Abate Lind Surface'
'Tip d code aNbr taw lend suffice rt., requki
awhines h idandR100with 16A NCAC 2C .0110.
5 Yap (op): So MEMO OF TEST At
ON N
30o2 A
4 3 1
f, DISINFECTION: Type -to°% 1411•1 Amount 2N0Z.
O• WATER ZONES (depth): ••-
From / c T From To
Fran 7 . ID From,
Fran To., _____ From___ To,
0, CASINO: Traction/
Depth
Fro'n._. _Q_ To38 Ft. laI " - Weight Malaria
P chi
From ToFt.
From To Ft._ ...
To
7. GROUT: Depth
Melortd
Fran O To 3 Ft. Po(zTuwa
Frain_ ^ To 20 _ FI. Bewroas of
Frc n ToFt.
PAP
O. SCREEN: Depth Diameter DX Ste MOM
Fran To Ft. In. h,
From To FI. In.
In.
Fran ToFt.in. h.
O. SAND/GRAVEL PACK:
Dirpth SIxe World
From__ TO Ft.
From ToFt.
From To Ft.
10. DRILLING L00
From To
0 10
t0 3qo
ll. REMARKS:
Formation Doopttlbn
&tow» D1na/Roc4C
GciPw►7E
d 2010
Information Processing Unit
DWQ/BOG
I CO IERIIY TWIT TI, Wsu WAS COMSTRNCIID N COOROMIOI wTrtM
11.1 MAC TO, WILL CON$TRuanow STAMM*, AND THAT A OM OF INS
RICORD M$ NNEIN PROm010 TO The Watt OWNER
oL- / 4-21-10
TURF OF-MIR-TM WEII CoP fR TOk
PRINTED NAME OF PERSO 0 G WEi i.
Submit tho QOM to IN Division of Water Quality within 30 days, Attn: hformsdon Mgt,
101T EIQ IIvks - Raleigh, NC 27999.141T Phone No. (919) 7334015 ext 666,
For 'i1s
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