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F S RESIDF_lV 7.AL WELL CONSTRUCTION RECORD
.5 :: '' •:-_--$�` - Notch Carolina of Fivimmmmt and Natural Resources-Division of Water Quality
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. �`,. :;,-- WELL CONTRACTOR CERTIFICATION# a-t$ q a- 1
1.WELLCONTRACtiOit: d.TOP OF CASING IS / ��� EL Above Land Surface` .
/I / /// Top of casino terminated attar surfacebelow land surface may requirerequire�Jh.. Ph , i S-,. it a varianceinaccordarice 15ANCAC2C.0118.
Well Contractor( e.YIELD(gpmx / ' METHOD OF TEST i ./`airy
75;tir IQI,'f/,, S,.:fly L,1:_T! Cad_ _ZCLc. L Type Ati7/ Amount ekyl
Weil Contactor( iy Name
STREET ADDRESS ak 3 01an.t.4 e I 9- WATER ZONES(depth):
From g/s? To 55 7 From - To
• Pl✓1 e-yy 0 Lf a..F. n G. c2.7 DA-7 From To From To
City&Town State Zip Code
• From To From To
61-
( code- Phone
� number y Z -
Area code- 7. CASING: Depth Diameter _Material
e /�
2WE.I.UiFOR6iATtON: From 0 To gii FL 9" SCI-y0 plasi-
SITE WELL m apere:gia) - From To Ft.
WELL CONSTRUCTION PHOAfi a ure, 41 Pat 3 -D/Z
From To ' R.
OTHER ASSOCIATED PEW/DT1 app§wble) . Method
3.WELL USE(ChedrA to Box)fi U "WWI': Depth nn
IndustrialfeonunercialD A8 h m From O To gir Ft. /"0 ego I, PD itreS
Irr afror�G Other! (Est use) b s .- e.5 t'L _ Fro To
DATE DRILLED /-a-(v_ 8 T) From To FL -
TIME COMPLETED ' - AMU PIYO 9. SCREEN: Depth Diameter Slot are Material
4.WELL LOCATION: Item To_rt FL in. in.
OTT: SAD n e v:11 COUNTY �� From To in. M.
//A./ 54- ,4 n 4 r a c /• `)i . 07-7 F) 18 From To FL in. In.
(Street mautar.members.Camay.Sobdivisbn.Lot No,Parcel.21P ) 10.SAND/GRAVEL PACK
TOPOGRAPHIC/LAND SETTBG _14_ft Sine Material
�Siope p Valley O Flat t] Ridge t, Other E To
(d Maybe is degrees.
-
LATITUDE 3 6`ag, g{' minims,seconds or From To FL
From - To FL
LONGITUDE 1)0 s .5.3 • 3 7 in a*am'cmmat
. Latide/longitude source: PS ! Topographic map 11From G LOG
tu Fom n
Warm Olsen!Boothe shown ona USGStopo inap and 6 y, .3 3.5 : P�./ ,rJ d i Marne G,•
attached to thi'sfrrmr ff not using GPS)
S.FACILTIY-Es the gwnio wee bus rresemasaisloated.
FACILITY IDU(ifappTlable) -•. _ ' -C K I V F'.�- .
NAME OF FACILITY /� •
III l 7(�7 3
STREET ADDRES• S
�► l
CSy or Town State '. lip Code _ . ��••�•u U'.'
CONTACT PERSON 6 b A ad 0P 0 kJ A e5
- MAILING ADDRESS 7 t/ .s 1- Ai 1,r...+'s h k _ -
itIfi iIP AC- ..27OyS 12.REMARKS:(�3� Town
9,51- 7State
a/ ..,/-%An eelI el/ 1) u-�. ' •0 Ga 1 v 54e41 reD
u.sink*
• 4'
Area ode-Phone number $l r/z.' G a/v+ 6 t l 2 ;k e d -1'o `$
8.1NELLDETAIL& IoerratEf3r CERTIFY TtinT THIS WELLWAS CONSTRUCTED Ri ACCORDANCE wmr
7 15A MAC 2C.WEIL CONSTRUCTION STANDARDS.AND TTH TACOPYORTDRS
a.TOTAL DEPTH: ],3 5 RECORD HAS PROVIDEDTOTIE WELL O IRA3.
'. b. DOES WELL REPLACE EXISTING WELL? YES! NO$ • S/G.-°2-
o.WATER LEVEL Below Top°Maslow N 5. FT. SIGN OF J WELL CONTRACTOR
JONiRACTDR DATE
(Use'+'If Above Top of Cosby) " fk7/ -/) —CM '`/ /? .
PRINTED NAME D'1 PERSON CONSTRUCTING THE WELL
-
Submit the Otfiebel to the Division of Water Quality within 30 days. AIM:Infoonation Mgt, Form GW-lb
1617 Mail Service C —Raleigh,NC 27599-1617 Phone Ha(919)733-7015 exEb69. Rev 12107
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