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RESIDENTIAL WELL CONSTRUCTIOI I tJ C RDa010
Notch Carolina Department of Fnvrronment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 6 5 o 0
1. L CONTRA TOR
Weir Contractor (Individual) Name
Wb -t;SERvica N c- •
Well Gantractor Gompan Namd `�
Nor44n,ttir013A .
Street Address
.12 t,54Z NC zffi
City or 1 own State Zip Code
(y),6 ) 4g3
Area code Phone number
2 WELL INFORMATION `/'��
WELL CONSTRUCTION PERMIT# Q U Q6 4L ? d
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELT If) *Ofapphcable}__T
3 WELL USE (Check Applicable Box) Residentiar Water Supply IJ
DATE DR II LED /D / Q9p
1 IMF COMPLETED_____ _ — AM p
4 WELL LOCATION
p 1 l ����(j f j
CITY il�+' ��i Y ++�.L '�v (&
__ COUNTY
l57 t/g_D eVVE LANE. Id Fr
(SIreet Name, Numbers Community Suhdivision t No , Parcel, zip Code)
E.IDEOGRAPHIC / LAND SETTING (check aaapproplate box)
M y10pe F1 Valley Li Flat Ridge I )Other
LA rrTUDF tsft jo ^,39i 5943 " MIS OR 3x xxxxxxxxx DD
I ONGITLID D`eL 31
L.iS DMS OR 7X XXXXxxXxX DD
I ahtude/longitude source pnps ( 1fopographic map
(tocatton of well must be S(pyyr1 an 0068 too nip R ttached to
MR form if not using GPS)
S, WELL OWNER
in a5 PArn..1.�
p-�C)wne,r,tvame
d Ninsr, cgs ith/1,te
PM i7
Sheer Address
6a. IVEAref v 1 le i- b•Ai gco
( fly or I own State Zip Code
Ama rode Phone number
6 WELL DETAILS,
a rot AL DEPTH p2 G 5
h DOES WELL REPLACE EXISTING WELL? YES [_l NO fir'
g WATER LEVEL Below top of Casino lQQ
(Use ' I-" if Above lop of Casing) FT
d TOP OF CASING IS _ J _ FT Above Land Surface"
*Top o1 t'BSinq terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2Cnn01�_18t /�
e YIELD (gpm) _IQ _ METHOD OF TESTOIDI i1�ft'MY
UISINFECTION• Type`�(34'E Amount
9 WATER ZONES (de
Top
Top _____ Bottom
1304Q111 `
th)
7. CASING' Depth
Tnp� Bottom 3cL
Top_ _ Bottom
Top___ Bottom
8 GROUT Depth
Top_ d Bottomo.
Top Bottom_
Bottom _~
9. SCREEN. Depth
Top Bottom
lop_ Bottom
f op___ Bottom
10 SAND/GRAVEL PACK
Depth
Top_ __Bottom^���
Top Bottom
Top Bottom
11 DRILLING LOG
Top Bottom
1
12 REMARKS
Top_ Bottomo21
3
Top Hoftom
Top �otlom__
Thickness/
DI$metpr W;eighht�Material
Ft III/
Ft
Ft - ---
Material Method
FtQorce
Ft
Ft
Diameter
Ft
Ft rn
in
F-t
Ft.«
Ft
Size
Slot Size Material
In
in
rn
MI NaI
Formation Description
t,A>\tt 43 6Z 2431(3
tCTiON_
Untt
i ,Sinr}
WA _ ion Proce
r DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER
SIGNATURE CERTIFIEDWELL CONTRACTOR ilk 6u
PRINTED NAME OF PERSON CON8iRUCTINGTTHE WELL
:',Lahmit within 30 days of, completion tb: Division of Water Quality - information Processing,
.!f t7 Mad Service Center. Ralaieh Nr 97aga_4aa ea....• ,ear., e,...