381347_Well Construction - GW1_20100225

RESIDENTIAL WELL CONSTRUCTION RECORD
North Caroline Department of Environment end Nstursl Resources- Division of Writer Qua!
WELL CONTRACTOR CERTIFICATION N A002.
1. WELL
CONTRACTOR:
=KANIi.IE l.. Qt wER
tame
STREET ADDRESS Usitt (net•LAr,
o 281! 2
dyOr Own tate Zip Code
} '1101:- 8o35
�ood0rnon0 number
WELL IMIORMATION:
srTE wELI ro wow*
STATE WELL PERRtrapps
eveffn
DWQ a OTHER PERMIT i1(M appdeebls) I00014421
WELL WE Ms* APPECIbte 00s): Residential Waiter Suppy 0
DATE DRILLED 2-y -10 Oott1
THE COMPLETED 3: 30 AM 0 PM t '
3. WELL LOCATION:
CITY Cis T couNTY ( ca-t,eNg„ad,
t-12.5 i,aTw Da.
TOPOGRAPHIC/LAND0 SETTING:
OW Ridge OOtMY
Oak W rOPdaN911)
LATITUDE .nL .i°
LONGflu a. £ f 41.5.91.14
May be In degrees,
minutes, won* or
in a decimal Ibrnat
Latitudellonsitudo some: GT(3PS pTopographic map
Avabssissimosta shown on a uses topo mop and
dschodbhi Item 'not My Opp
4 WELL OWNER
OWNER" NAME EAw A� I- L ,—
STREET ADMEN _5725 gar,►• t &q
CHq(L T NL
or oan .. Stets 2
3(03-(ootoo Zip Code
^�'vMa 0coodc0� • hone nun er
SO WELL DETAILS:
a TOTAL DJT'&.._„ 50
b, D061 WELL REPLACE EXISTING WELL? YES o NO (,$'
a WATER LEVEL Below Top or Casing: 25 FT.
(Use'? WAODN Top of Casing)
d. TOP OF CASINO NI 1 FT, Above Land Surfing'
'wanes a00md/1o0uthr ih 115A bobs lend
Q 1may rewire
a YMU) (�^r---.: c.. METHOD OF TEST AIL.
I. DISINFECTION: Type 10% Fly.1 Amoent „?(, as;
9. WATER ZONES (depth)
From _5 _ T _ From — TO
m_ Fro"ToFromTo
From ; o To From — TO�,�
0. CASINO; l0 ssj
FromFrorn h 38 Ft _Diameter
r t ' SA& 2r
To__. ___ Ft
From To Ft
T.OROVT: Depth Materiel
From ToFt.
From ToFt
Frpn_+ To Ft
0. SCREEN:
From
From
From
Depth Diameter Slot Otte Monde
ToFt In. In.
ToFt In. at
To ___ Ft In. in
0. SAND/GRAVEL PACK:
Depth Size MatlwW
From ToFt.,__
From ToFt.
From To Ft.
10. DRILLING LOG
From To
0 9 1304.10 CI"
l8 &.o'-. Aare
/8 gy QRos+r 14 Pca.
2. So
Formation Daglptbn
agAtisTE
l .1 I 'V/ i
�►-R 152019
11, REMARKS: Is)rorrnai"on P ocessang Unit
1 DD WRIST CIRTVW THAT 1!q WELL WAS CONa1RJCIEO NNICORDANCI %NTII
iM NCAC /C. WILL CONSTRUCTION RUCTION STANDARDS. N41HATACOPY ORTIM
RICORD KA$ SEEN ►RO 1010 TO THE WELL OWNER
Z-/9-ro
R E _��� .�-� °—"IiRf
g4n+141€ I.. LA vea.
PRINTED NAME OF PERSON CONSTRUCTING THEVELL
Submit the original to the Division of Water Quality within 30 days, Attn: Information Mgt.,
1017 Map Service Center.. Raleigh, NC 27699-1617 Phone No. [phone] ext 655.