381344_Well Construction - GW1_20100225

1. WILL CONTRACTOR:
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North Carolina Department of Environment and Natural Resources. Division of Water Quality
WELL CONTRACTOR CERTIFICATION N_ poZ
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STREET ADDRESS (011
MON(IoE
"pmNC 112.
Code
_• WELL INPORMATION:
EMI WELL ID # Vappll Wie)
STATE WELL PERMITpr, ,
DWQ a OTHER PERMIT Nor aPPlIcebl.)
WELL USE (Check APPaoable Coto: Residential Wets Supply 3' DATE mum, 2- J$- to
TIME COMPLETED S s Dp
Am S. WELL LOCATION. 0 PM (�''
CITY: WAxFln,.s
COUNTY MroN
OC/ SETTING:
MP
Meal WWII* aR O Otha
UTI ex _ ° 5(0 .'-r»ro rJ Ms), be In deems,
ONQIiUpE $ p minutes.
L ° 3 In a dicimalIb
. (o(o) CJ mm
wal NUM: SOPS Topographic map
Mbch d toallot an a usos topo map snd
not t
S. WELL OWNER
LopoPSJ
OWNER1 NAME T ^^ es
STREET ADDRESS -70 Tnr P,NE
or oIAtI t«' code
lFoo-91
/0-22
. WSU. DETAILS:
.a TOTAL Dint 206
a Does wau.REPLACO SXISTTNG WELL? YES I1( No p
WATER LtVB. i lIEWTip o/ Casing: 30 FT.
(Wow 'Atom Top of Casing)
d.. TOP CP CASINO. p I
'Toad ening FT. Above Land SuAws•
• mime h exacting* ` CACilar bobs land p 1 R�In
0.
a VIED IMP...__ METHOD OF TEST AO.
I. DISINFECTION: Typo 20 j
O. WATER ZONES (depth):
From (1:2- To
From_ To
From_2 To
0. CASINO:
From C>
From
From
a NTt4
From
From
From
DeJE_
.
7.ON Depth
nMetsrtei
F�--.a. To m FL alicrLEWo
FromFrom'" Toy+ Ft. aet+InwtTE
To FI.__
0. SCREEN: Depth
From To
From , _ To
From To
0. SAND/ORAYEL PACK:
Depth Six.
From ToFt.
From To Ft.___._
From To Ft._
10. DRILLING LOG
From . To
O (0
3 11 3 4, 4
Amount 14 o z.
/2e To,
To
To
nwtlon.v
SDR ?d AIt
Diameter Slot Ste MOM
Ft. in. In.
Ft. In, „,
Ft. In. M.
World
Formation Descrotbn
Pen C4A4
Z Qita.+a SANG
� S is
Laos sewft
28 zoo Q caw,.,. SANasro,•L
o GF.,4riTE
11. REMARKS:
:,torrnat OI p oc s 'ng Unit
DO IlRIIY CORM TWAT TWO Wall WAS CONrIRUCTED NADOORON11E WSW
kIA NCAC tC, WILL CON$1W,C ON STANDARDS. ANDTNATACOPY OFIII
RICORD HA1 SEEN PROVIDED To Tite welt OWNER
2 •
e,ArJWS L . OuieQ-
PRINTED NAME OF PERSON CONSTRUCTING vie WELL
8ubmfl the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1017 Map OiMee Center_ Raleigh, KC 27096.1617 Phone No. (919) T334016 axt 666.