386741_Well Construction - GW1_20100827

RESIDENTIAL WELL C N$TRucnON RECORD 3 8 6 7 41
North Carolina Department of Environment and Natural Resources- Division of Wear Quoin).
WELL CONTRACTOR CERTIFICATION N 3001 A
1. WELL CONTRACTORt
faNILIC L - OLwat.
Wd Caninotor (bdMduilf N.me
0.1)floL-tA+A 1 JEg.c bP- 4_r.4G
Wit Conboctoraomp*ry Nemo STREET ADDRESS foloRi /J%w.. a.
ChycrTom State Zip Code
(( 704 } 7bLI -845
Me code Phone number
S. WILL P ORMAT1ON;
SITE WELL ID Nr avFuoeore)
STATE WELL PERMTM(v epp.osere)
DWG or OTHER PERMIT t1(N eppno.ble) /Goo/l' 17
MUM 1/Sa (Check Apploebl. Ow): ReeldentiN Water Supply Lir
Di1TEO!mLED S-ID--10
TIMa COMPLETED / 2.00 AM O PM (S'
3. WELL LOCCATICNt
Ciy CHA¢LoTTE
COVNTYrnEGiie#8Ua6
$boo VAGA(OND Po
1 s 10uee. * a of )
TOPOGRAPHIC / AND SETTING:
fiNope DVIky Oft DRidge 10 Other
tt RR ppgrlebbwo
urtTTIUDE .8.1: I I .770, fJ
mow= am 9 7 5 5 W
May be In dhow,
minutes, swords a
In a decimal Ibrrrnt
)LatiNds4oi ptlo : t'OPS pTopognphlc msp
(taboo/ paad a shown on a VSO$ topo map aid
NbdNd b Ibrm I not why GPS)
d. WILL OMNWR
mints NAg mu( iZ sEk g,
STREITADORMS 05 ssEr i`
Ca° /41c 2821-7
or Om tM zip
( 70'Y . NZ—va31
A+fai OOd1 • hay mote
S►WILL°PAU:
a. TOTAL DtpTH _2o0 `
b, DCS$MLLR!PLACI !COSTING WELL? YES D NO
o. WATIIR LEVIL IwowTcp of Owing: 41 FT.
(11.1'.' MAMoite Top of Casing
d. TOP OF CAMS IS I PT, Awe Land !Mho,'
lop d css Mrmlostod eft beivw hand .urteo. Pity regebe
.rElako.h fto/ordmoewatt 15A NCAC 2C ,011e.
f , YIRDItPm): sMETHOD OF TOT P-
t, gSINFECTION: Type
10 "l Amount 0 :
9, WATER ZONES (depth)
PIS To From TO�,�..._.
!(on • -re — From,
17/ To FromTO,
Tltloateeel
From,
From,
Fran
/, CASINO: �1�w11
Depth
Ol meter Weight
GAu�
From 0 To /3o Ft to
Fran 0 To - l Ft, 1,'1R" �..�—
From To Ft
1.OROVT: Depth Materiel MROIod
From 0 To Ft.
Fran To Fl.��.�••.-••
From_,. To Ft.
1. SCREEN:
From
Fromw
From
Depth
T o.
.. To
D,•met.r Sat eta
FI.In, In,
FI In. h.
To Fl In h.
I. EANDlORAVEL PACK:
Depth Otte MewrW
From To Ft._.,_�......�..
From To Ft.__.__.,_
Fran To Ft._,,,_.._ ..._.._..
10. DRILLING LOO
From To AlomlitiOn
0 q Ken rea-
4 58
58 /05
10S /Kp
!I(o 2oo
11, REMARKS:
WWI
In ormauon oocesstr'g Unit
DWQ/BOG
100 REMMY CERTIFY THAT TEN WRl WAS M WOOON41rAR1
IIA NCAC tC, WILL Oot*TRIJOTION STAIIOARDS. AND MAT ACOPY CO The
etCCItD to. MN FIIO iotO TV TM Will OWINA
Weimele
R -TSAR OF f R8O�
Submit the ollpinsj to tho Divfston of Water Quality within 30 days, Attn: Information Mgt,
11111 Owls Center -Raleigh, NC 275994517 Phone No. (919) T334015 att 550,