381345_Well Construction - GW1_20100225

C
Of ' ' state Zip Code
7�_^'�t_} 3to3 -1544
a WEL DETAILS:
TOTAL DEPTIe
e. DOES WEr1L REPLACE EXISTING WEILL? YES 0
e. WATER LEVEL eNowTop or Casino: 35
NN'*' 1AboVe Top at Casing)
d.. TOP OF CASINO q I FT. Above Laid Wear of poky%Mmin11 r bs)Orhr land surface may retake
s Minh sOcoFdInCe elf h 1OA NCAC 2C .0110.
L YIELD (gpm): __2_.. METHOD OF TEST AIR.
f. DISINFECTION: Typo 1010 t+nI
0, WATER ZONES (depth):
Fran To
From_ To_•„_
From 1 2 To
0. CASINO:
Depth Dlemeter
Fran 0 To 4 2 Ft.
Fran
ToFt.
To Ft._
Amount 20 o z •
From 93 To
From /')o To
From To
ThIalttN w
Weight
Materiel
a. Zs p
VC.
7. GROUT: Depth Matte
From 0 To 3 Ft. Portn,AKA
FroFrom_ To 354- Ft- (3sprui- �'r6
T Ft.
E. SCREEN: Depth aarneter Slot eke Mabry
From To FI.•____,In. ln,
Fran To Ft. In. - In.
Frames_ ToFt. __In. In,
0, SAND/GRAVEL PACK:
Depth Size Wield
From To_,,___ Ft.
From To�,_„•" Ft._.._w
From To Ft.
10. DRIIUNG LOG
From To
0 3
3 ig
11. REMARKS:
Formetbn Desaiptbn
et c.. t
QROwN D.o:thocAL
BtAAE SL-CKic QOc.*e
DOl#ROY CORM THAT TIW Wall WAS CONS1RNOTEONAt)OORQANCI NEW
tIA NCAC IC. WILL CONSTRUCMOw STANDARDS. NOWAY A COPY OF TIM
RECORD WI PEEN PROVIDED TO THE WELL OWNER
N14-16-. L O1.W6I-
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days, Attn: Informsdon Mgt.,
1017 Nap aenice Center- Ri1i1gh, plc 27599-1017 Phone No. (919) 7334015 elct 666,
•
OWNER'S NAME
STREET ADDRESS
1. WELL CONTRACTOR:
ll)WS MC
RESIDENTIAL WELL CONS
UCTION RECORD 3'� .t e ^-
North Carolina Department of Environment end Natural Resources- DIvleion of Water Quality
WELL CONTRACTOR CERTIFICATION N 3OO2-
N . , or . . `erne
STREET ADDRESS (otoly MEIN RD.
t' lo..cw N� 2.$i12
CI OM tato Zip Code
"Tod
�Nor1i nunwer .�.
& WELL INFORMATION:
SITE WELL ID ORece eabe)
STATE WELL PERMIToweep ).
DWQ a OTHER PERMIT log applicable/
WELL WE (Chet* Appliaabie Box): Residential Water Supply ay
OATEMum 2-11- to
TIMECORIPLETED 3'0o AM0 PM(e
3. WELL LOCATION:
CITY: mopROE COUNTY U,,tos
Pa-ostnci- ESTATes 1..421- 411
TOPOGRAPHIC / LAND SETTING:
cep., ov. E 0R� DOD's'
eFiteprlale
IAT �...�° I - to &r ,u
LONGITUDE S O ° 37. 1 I to
Latitude/Inhale a um:
• Mc+axydnlaSmoltbg I>'iOPS pTopo�gphio map
ENO Ib rlbw I shown On a U308 tope map and
1. WELL OWNER not uahp vs)
OVRIER18NAME eLt -mom ass-F CA'lor
eTR@T ADORLEs P o ,
fox 931
of
s��flw
0 • 1301‘ 93 %
W. ..._.. ic,.
OWN ' State
VIEUF�'honE nun e g
aL DETAILS*
al. TOTAL cent: 2 op'
b DOES WELL REPLACE EXISTING WELLS YES p
e. WATER LEVEL Now Tap of Comm: 35
(Uae'+' 1 A*, Top o/ Casing)
d.. TOPS CASINO IS I
FT. Above Land Surface'
e memo,h exadonoe Wth 15A NCCAAC 2C 011 Wits
YMI,p Wm): I °.... METHOD OF TEST A+R
09-219
Msy be In degrees,
minute, aoonde Of
Ina decimal knee:
,, . .
F.
!VP
Rot. TIM
aT1o.+
NO('
FT.
Submit the original to the Division of Water Quality within 30 days, Attn; tnformedon Mgt,
1117 Nap flansla Center_ Raleigh, NC Z7099.i511 Phone No. [phone] •Xt See,
Zip Code
NO er
FT,
11. REMARKS:
•
. ....,�„ •a.. . v.
-E13 25 2818
iouriT112 iOii r.
DWQ/BOG
DO !VIM CORTRY THAT MI Well WAS CONSTRNOfEDNAOCORONICIIIMI
RSA NCAC 2C, WILL COMMOTION STANOAROI. AND 1WT A COPY OF TIM RECORD MI SEEN PROVIDED TO THE wet./ OWNER.
8I0 R p
tWirJi�lE L.OtAjeg-
PRINTED NAME OF PERSON CONSTRUCTING TILE WELL
2-l4--ro.
a►it=.
Farpi Intls .
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