380572_Well Construction - GW1_20100129

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RESIDENTIAL WELL ooNsTRUCTJON RECORD 3 -'0 5
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION
1. WELL CONTRACTOR:
t� L.OuvIIL
tr a
war LAuo�t�A.N`
ntractor WOO
STREETADDRE80 ME11 (6
o L.E L 2$112
Own : fats Zip Code
b - 8085
mane mum s
*. WELL INFORMATION:
SRQ wELL ro IR epplaselo
STATE WELL PERMI 'S(' epplioselel
DWQ a OTHER PERMIT S(1► appde )
WELL USE (Chick Applicable Sox): Residential Water Supp1Y 0
DATE MusD / - /5- /O 19-046to,N 0 N L I
TIME COMM,ETED 5: ;o
AM
i. WELL LOCATION:
Cn'Y;
COUNTY U►JtoN
TOPOGRAPHIC/OLAND SETTING:
Wok M,/ Old 0 Ridge OOthan
WWI*
LATITUDE / • OlJ Q2'fi w
LONW $ Q '1 W
Latituddlonsitude source: dons OTopographlc map
I'SCeabn.afNwnut b, shown one uSG$ topo map and
NIschidldrilo bro not why GPS)
1, WELL OWNER
OWNER'S NAME E 2ao pLjANN t
STREETADDRESB 222RAIA js
N28113
ams
•
•
oq-- Z2$
PMar
wryor G NI Stets Zip Cods
,O`� 2oi- 13
M. be In degrees,
minutes, ssccnds or
Ina dsoimsi Ibrnai
5 WELL DETAILS:
a TOTAL DIM 376'
b. DOE/ W!u. REPLACE EXISTING WELL? YES p NO El
a WATER LEVEL lobe Top of Casing: 20 FT.
(DN'+' IAbsie Top of Casing)
d. TOP OF CASING 11 I FT. Abon Land Surface'
fop d casing Nal* st/w bekw and woof MIT rsauks
' Mot a l) madame M b 15A NCAC 2C .0118.
0' MD (Epna): METHOD OF TEST Ak2
1, DISINFECTION: Type
e• WATER ZONES (dapth):
From 330 To
From�3 p__To,
Fran_ To
S. CASINO:
Fran Depth Diameter,
�_ To C;O Ft., Co'/R"
From___To SO Ft. LP'°
From To
ToFt._
'.GROUT: Depth
(p'/S,. Fran
rq .0 ToZ Ft.
From D . To 8D _ FI.
From To Ft.
Amount o z .
S. SCREEN: Depth
From To
From To
From To
S. SAND/GRAVEL PACK:
Depth
Fran To Ft.
Fran ToFt.
From To FL.
10. DRILLING L00
From To
11. REMARKS:
�" LiArea. /..s r itls Ta To Sllh. of-F
LOOSE ?ocee Sys Lo3'-478'
From
From
F►om.
To
To
To
Thickness/
moot meow
t'R Vc.
Material
r a.rire
Diameter Slot SEe Moral
FI.in. h,
Ft. In. h,
Ft. In. In.
Size World
Fom*tbn Devalpgon
8 w", Dian
w..+ CuW ANIN
20 wn. 'Poor, /.<ANA
!rm i- ram. p
JAN 2 D 20%
pr®Cessing Unit
CO WRIST CERTFY TNAT MO Wall WAS CONSTRUCTED N ADOOROMNI tNTN
ISA ICAC ZC, WILL CONSTRUCTON STANDARDS. AND TWIT A COPY CC 11N
RECCRD HAS SEIN PROWDED TO THE WELL OWNER
/-25-/0
SIG TURE 0 E - ED WEII CORTRACTOfs
1>J1uE L. OuvQ-
ORINTED NAME OF PERSON CONSTRUCTING /HE WELL
Submit the original to the Division of Wstor Quality within 30 days, Attn: Information Mgt.,
1.17 Mall lfenflttsfir- Raleigh, NC 275911.1S17 Phone No. (E1E) T334015 ext 555,