386368_Well Construction - GW1_20100817

RESIDENTIALRESIDENTIAIGNALLS&BAIRUCTISZEige&BR
North Caroline Department of Environment and Nstunt Resources- DIvIston of Water Qu.thy
WELL CONTRACTOR CERTIFICATION N 3oO2. A
I. PISINPECTtON: Type '70°10 *LW Amount
•. WATER EONS, (depth):
i 3 S To From,
I(o0 • ToFrom,
170 To From,
1. WRL OONTRAOTOR:
gRAHWE L - 0 L»J'I Q
W.1 Cantrsotor (Ytdlritltt Rasme
? ,�e-u- bo-ttAAA
Well Comisacto► Ocmpany Name
STREET ADDRESS
(9(144 1 �m;'lLIA PA.
2811a.
City or Town Stag
6)W Phone number
Zip code
IL VAIL OGIATION:
stTE wELL ID RI •Fpta.ea)
STATE; WELL PERMiTMp pplbabtel
OWQ or OTHER PERMR.(M sppnc.blel I -13S
MUM (Check Applicable Boo: RestOenttei Water Supply 2'
DATID LU= 8 3-to
TINS COUPLETW 3 =oo
& WIIILL LOCATION: ^, `
CITY: • "'omf
�ezw mebIL,, RA.
( s Nibs* C•Nsnun y, Subdvloion, Lot No., Prroel, Zip Co*:
TOPOGRAPHIC ILAND SETTING:
DSbp OVMry 111(Fist ORidpe OOther
bag
t.ATRiJDE .L Li° (4q. it.9 t
LONOITVDe g O' 25. q_1 w
Latitudeitonsitek IS'O3PS OTopographic msp
• of *•lftwnpp shown on , IVSG$ tope map •rd
desc odb11it Itrm gnot whip OPS)
d►wlLLOwNER ..
ow.N5RI NMI AvIsur (.00 S-
immer =Rfl 2 ' f Many,/ [L.,,
442.4 NC Z$U 2
�. own ' ' Stith Zip Goa--
viuNli aod� • Phole unbro9
WILL OVAL*
Err TOTAL own!: '
a MIS WILL INMAN EXISTING WILL? YES p NO (e
L WATER LEVL Odo r Top of Cooing: T.
Noe NA*, Top of Casino)
d.. TOP:CAMP 1 FT, Above Lend SuVsa'
'Top d 0s1Y10 Wm Mled War below wind lvane nwy require
• who* In l000rdintoevat 15A NCAC ZC ,011t),
Of Tear A2-
AM p 'PM Cd°
couNTY
May be In ds/ess,
minute %s.00rde or
Ins decimal Rtrm.t
From,
From,
' From
To
/2- 0 L.
To
O. CASINO: ThbbtssW
Pepin �g,�rl�leter s z,‘ JC
Frwn 0 , Ft•�t."r a Salmi
From To Ft._,_,.
From To Ft.
T. OROVT: Depth
From O To 3 Ft.
From 3 To 3 S P.
Frwr To F1.
1, SCREEN:
From_,,
From
From
Depth
To
To
To
t. SAND GRAVEL PACK:
Depth
From ___ To
Fran��To
Fran To
10, DRILLING LOG
From To
"1
I'F 68
modelttasvt
2tt.ANA --��--1" iha-
�
,�,+ItV mow_'
Dlernetes Slot Sip tsrw
Ft. In. h.
Ft. In. h.
F1. In. In.
SOX Metartd
Ft.,.__,.._
Ft..�......�
Ft._........�
RAMIE DiscroPezi
( L • /op 84p4a.+ 6-cAtl
i /to
I to ?OSs
11. REMARKS:
&Za '- QvGL
ssSt„4
inkp1matioon Pc
DO ISRQY CSRTVI' TAT TIA WELL WAS OOIISTINIQIID M AODO SPAN OW
IIA ?CAC tcc, WILL ootfsTRUOTtON ITANDAADS. AW TINT A COPY OF MS
RICCRD FAA MIN PItOWOID TO TN! WILL OW►R .
t'wArgUE L - Ot.ty�
ORtNTED NAME OF PARSON l W ••
•
8ubmRt a original to the Division of Water Quality within 30 days, Attn: Information Mgt.,
1$17 Mql S41** WAN- Raleigh, NC 275994511 Photo No. (919) /334015 Olt': 555,
pt�1� . .
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