385299_Well Construction - GW1_20100719

RESLPENTIAL WELL CQbSTRUCT1ON RECORD
North Carolina Depenment of Environment and Nonni Resources. Division of Water Quelhy
WELL CONTRACTOR CERTIFICATION M 3COZ A
1. WELL OONTRACTORI
STREET ADDRESS isiallf (Vie/NUN PO •
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or Owns IP C
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t; WILL INFORMATION;
SITE WELL ID OReppsosON)
STATE WELL PERMITRIroposobiol
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0 wi Pali Appicable poor): Fteeldermer Water Sup* D
plunk_Ari IQ.QL( 1)o.►j ONLY
TIME oomPLETEo / 2 ou AntI 0 PM GY
S• WII LOCATION:
�: CalA,rttorT
COUNTY Mecatz'aiy6
/0535 L.avn /n/
'1•r. �5 lO ra.•{E In.
TOPOGR �/ SETTING:
Dip' Mope OOther
LATITUo' j• 5° 08. )59t,
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ttoilb,0110/ MoN be shown on
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or CiAll
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a WE L DSTAILI1
E, TOTAL OEI R 24:01
a Don p01mama WELL 7 YEW NO V
WATER MIL Mar T
(Um II a T« Casing: IFS FT.
4 TbPofclan a I
May be In dams.,
minutes, seconds or
Ina doolrrwl Mmel
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3�299
I• DISINFECTION: Typo 1o°io & 44 Arnow'
S' WATER ZONES (depth).
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10, DRILLING LOG
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RECICI\/ a
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11. REMARKS; JUL 1 9 2010
Information
M ct BOG
DO ► MIY GIMPY THAT T10t WELL WAS 0011ITENICRD W ADOCIOANOI ItA}M
I IA MAC lc, WILL OORSTRUallON STANDARDS. ARDENT A COPY CF INS
11VCCr1D HAS IRIN PACAnotO TO THt Wtu OWNER
IJIr:iC L.Oi.wbi2
ORINTED Nogg OF PERSON 00174YRK111411EAVEll
lU the Division of Water Quality within 30 days, Attn: hformadon Mgt.,
Raleigh, NC 27699.1$11 Phone No. (919) 7334016 ent 6150,
ram 04yo,.
1/05