386164_Well Construction - GW1_20100811

1. wm.L ooNTRACTOR:
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RESIDENTIAL WELL- CONSTRUCTION RRCORD
Nofth Caroline Department or Environment and Natural Resource*. Division of Water Qudhy 3 8 6 1. 6 4
WELL CONTRACTOR CERTIFICATION N 3002. A
Amount 2
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number
L W5.L INFORMATION; •
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STATE WELL PERMTS(/.Fpaoata)
OWQ a OTHER PERMIT «pr _ppaoabN) to - SFt
MUM (Check AppSoablo Box): Reektentld Water Suppy W
DATR acuso Z -2 - to
TYE CometsTW l Z t oo AM O PM iV
S. WELL LOCATION;
CITY: MoaIDE cov - 1 t
3b32Nti (3fLQo Low
a l
TOPOGRAPHIC / WED GETTING:
Dabp.. DWI* Comet DROP DOther
( wpwdeerOw)
LATITUDE . 4 ° 61.15( g
LONGITUDE L O ° 3� 7. 7 s 4 G)
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ttoNb miliNin stOw shy+ t on • VSGS typo mil) end
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A. MULL OWIIR
MEWS NAME__C - - A ors ae-0
5TREETADDREsa _Po . Qo•u. 931
U..)Ahnaa„>' c- 2.8 13
Cyr a Torte • • OWN Zip Cot
7( 843- 4133E
Nri ood� • Plus nulibu
WILL DRAM
a TOTAL OMR 3301
th Me WILL REPLACM OWING WeI, ? TER D NO ®'
a MAIM LIM alllo*Top of Carving: 3S_,FT..
(UN'*' M Abort Top d Casino)
d. TOP OF OAaNv I ( FT, Above Lend curlew
'Top d os111p Mnlin.hd eft be)ow into vurtea Mary requke
swim h s000rduloe wth 1 SA NCAC ?C .0110.
9. nip Wm): I MCTHOP Of TUT 6�Q
Maya In Owen,
minute.. seconds a
Ina dieing Panel
f, DISINFECTION: Type l0)10 turd
e. WAT1R ZONES (depth):
From 5 Tom^, Fran To,
From 10 3 • ToFrom,
Fran I$D To From To
0, CASINO:
Depth Diameter
Fran 0 To 41 Ft. [v'1R"
From _ To Ft.
From
To Ft.
1.OROVT: Depth
From0 To 3 Ft.
Fran3 To S , Ft. ENTD,4
From �w To F1.•,�^�.-
Material
Te„•••••••••._
ThlobNn►
S�zr Material
0. SCREEN: Depth
Fran To_
From To.
From To
t. SANO/ORAVEI PACK:
Depth
Fran TO
FranTo
Fran To
Diameter eta Otte
Ft. In. h.
Fl. In. h.
Ft. In. h.
10. DRILLING LOG
From To
Q q
9 2t
LI 33o
11. REMARKS:
MOM
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akTL 19
tnie _ _
ntormce
ation Prossi^.^ t -- -
DWQ/BOG
1001ERIIY CORM THAT 1100 WILL WAS CONFRUCTI0NA0IXONC4 NM
I IA IICAC 1pp, WILL CCNIIRNCTlow IIITANOAROS. NC THAT A COPY CONS
nICOn0 FAO RIH ntOVIDIO TO TM! WILL OWNER
ttie L O tAvea
ORtNTEO NAME OF PERSON tONSTRUCTINMWEU.
Submit tlit WOW to the Division of Wstsr Quality within 30 drays, Attn: Information Mgt,
1017 Mail WON Canter- Raleigh, NC 27549.1517 Phone No. (919) n34015 nxt 550,
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Fain trili
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