404106_Well Construction - GW1_20120402

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WELL C: It3P.(.MDr. NAME (print)
VVELI, Ce: ' :*. CO 04E . 2-13!
STATE v:.? `2:1 : AssocRATr.: PERMIT*?
:I' .pesp.litable)
PROW
go7)ricable )
• . •
)1.3j.CATI1OPI ?
1. WEI. "d'a ',Check Box): Residential r1 l'Aunicipal/Public.! industrial 0 Agr'.; ultural 0
.;3, 1:3 .Recove: it Pump Water Il*ion 0 Other 05.fOther. List Use „...7,e,e1144),)
2.
Nea113. t • ..". ! Ld/.!t.q11,0e- County.
(Strel:2; ; 1:umbers, Ctn. :.. .it ;. f4,bdlyision. Lot WO, hip C .to)
3. OV.n.1
Ado3.1 5 • _ .77:4,:s2c
(street fin' i4a.)
.41.11 f.I#4
' -13011 5.
Amo !:ti t.e siumber
DATA ; 3 .7
s. T07.,( .;.,
6_ DO'1,! REPLAES .7:1l\IG WELL? WI: NO E
7. STA 1 tsTiat LEV .*:1 a X Top of Cash*:
a (USe "+" ifAbove Top of
8. TOP I ;; IS FT, Above Lane .1 rface . •
•••
; ;v7, tereatInde0 z ;,..tp laad surtbee naquires ti
.ecirclatpoz: .". 2C.0118.
9. i';TROD OF TEST_12,741.149._,‘
10. WA1";: ' (deptil
Zip Code
11. DIM Amount
12. CAE..',1:.:7 Wall Thicim,:ss
Depth or Wig/
••• ••••••
Fro4,1,/,7,!
From_
Front_
13. GIC:11.1
Fran:
Fro c
14. SCR I':
To
••
Depth
To p2
To
Depth
From., ...VIC Tof.
Ikon t_ _
15. SAME :
Depth
Fr0111.. To :FL
Front
To
J
•••••••••• ••••• •••••••••••• ••••••••• •••••••• • • •• •
T.
o 4/40- ::!. a... $cYo
Diameter
,
. , ... ._..........• •... . ,.....
To ; (.. _
:.,
16. R.Eiv:,
•. so • MMairm.elo.
Material
lows.
••••
•••
Wisteria'
Method
:IY.cfneter Slot Size Material
't itv. 0/0 in. _
...„
tn. tn.
Size Mama:
••••••,••110.40....4Wisksa.
••••••• • •
••••••••• •1•11.••••
Topographic/L.r.;..;t3 s wing
[Midge C1Slope t 1111E
(check appropr el'ox)
Latituddiongitude c cit location
(degrees/minute: ;:i7ttd.5)
Latlit;I:l.e.flOrtgittde SOUTCVOC:. :liCITopotraphic map
;I: 1)0N)
riMMQ100.
r.ralition Description
coArs
Frorr To
• ••••• ••••••• ••••••••••
•••• ••••.• • • ••••••••••
•
A.041.•••••••••••• ...............••••••••••••1111•0101.4.4
••,.....‘•
•••••••••.•••••••••••••• ••••••• • • ••••••••.•••••••••
1.9.•••••••••••11W........041 MAVIP ,•••••••••
xxicArtlx.) 53:31
Show .rirection and distance it ! miles from Veva.
two. Sme Roads or County :F..: als. Include
nurntimr. and common road r zits,
•••••••••
...110.111MINIMP.1%
APR 0 2 2012
By
1/4/ ID
(...k A
1 DO trIEF:1 1.1 'WY TO :!';.S WELL WAS CONSTRLICTED IN ACCORDAV:CE WITR 15A NCAC C, WELL
CONSTRU • STAMAI1.„; 041) THAT A COPY OP THil3 RECORD 5 tr‘ 1k1 PROVIDED TO Mr; Vial. OWNER
ON:
STRIJ
42,
IN 138 WELL
SubmOt a 1 to era) .;" oirWater linfonsettom Ita.Unesmett, 1617 Mai !:; Caller
&IWO, 49) 733-7015. WItTs's!u: 'ID asses.
(I'Vt.t...1 REV. 09/2004
RECEIVED 03-26-'12 14:49 FROM- 9103133102
MAR 2 7 2012
TO- NC DENmat..7lionPLocelr„ssp0 03-a 11
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