381744_Well Construction - GW1_20100318

1. WALL CONTRACTOR:
RESIDENTIAL WELL_ CON TI UON RECORD
North Carolina Department of Environment and Natural Resources. Division of Water Quality
WELL CONTRACTOR CERTIFICATION TT 30o2.
Rao t,. Ot•IVeit
I�r or ante
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ar ttrt,a
STREET ADDRESS (4014 Mat4m 94.
fmo.spt C
brm 28 a l'Z
ww, tir
ratoer
2 WELL INPORMATION:
sRE WELL ID rprepplingle)
STATE WELL PER „{p upplium.
DWQ w OTHER PERMIT Pm Epp floes)
MUM (Cheep AppSp4 Boor): Raldentlat Water Supply Ur
DATE omu.sa 2 -Llo'lo
TWE COMRETED bo AM 0
PM (g'
3. WELL LOCATION:
CITY:
COUNTY U rloa
4014 1 M ca BWA.
OOO APMC/LAND SETTING:
M ak WSny (811tt OOther
eppreplals
IATITUDE .,1...t° t, 52i N
LONGITUDE g o° f. 928 GJ
Vtion** source: (d(3PS CTopognphtc map
' Amboy/ Waist be +nose,► on It V$OS topo map and
aftechaltoV*Ibrm/nogg OP$)
�WOLL O'MIER
OWNER'S NAME s Ile
STREETADDRENO Yot Mc 't'4: b✓o
13 _
10 - O")
May be In ds s's,
minutes. seconds or
In a decimal Former
Or 0NA ' StatC.
e
�oY 771- 038?
Zip Code
a WI LL DETAILS:
al. TOTAL DEPTF! 300'
b. Do!i WELL REPLACE IDOSTING WELL? YES to NO p'
O. WATER LIM Now Top d CM
NN'+• ItAbw• Top d Cawing) �o FT.
d. TCP OF CA1ING I$ 1 FT. Above Land Surfao0•
Top d NOV Nan i'ticr beim land aurteoa may Mon
aMom h madamvAth 15A NCAC 2C .0118,
99 YIELD (Mr— //2- METHOD OF TEST ,p.
3
4 4.
T. DISINFECTION: Typ• e o Amount ►$ o z
Amount
g. WATER ZONES (depth):
From To
From 2,o _"To'!
2KS
From To -
From Z?o To
From To
From To
0. CASINO: ThioloveWr
From10 _ Depth /t{S D se ttr MVO
Ft. li o✓R • /8k
From To,_ Ft.
Fran T Ft
7. GROUT: ,_Depth
From^ + To�L Ft,
From To 3 , Ft.
FromFt.,
0. SCREEN:
From
From
From
Depth
To
_ To
_ To_
0, SAND/GRAVEL PACK:
Depth
From To_.,__
From . Tom Ft
From To Ft.
Materiel
Diameter Slot 8toe
FI.___In. h.
Ft. In. h,
Ft. In. h.
10, DRIUJNO LOG
From To
0 29
Ito
lac
11. REMARKS:
8lze
Ft.
World
Malarial
/Famnion Deaalptbn
QQ+Aur Dior
.S9 ASao.08
IviM1H`U10,
Information I-ro.
DO mitt Y CORM THAT THIS Well WAS ocNITRYC1E0 NAOOORONI I mitt
NA NCAC IC, WILL CON$TRUOTION STANDARDS. AND TWAT ACOFYCFTIM
RECORD NAe NEEN ►110M0E0 TO THE WEIt OWNER
b1w. OcpZ !� — 3-1- /0
IOR
gorcaE G. Ou✓6Q •
PRINTED NAME OF PERSON CONSTRUCTINOIN EU.
Submit the original to the Division of Water Quality within 30 days, Attn: Information Mgt.,
1017 Mall knit. fir- Raleigh, NC 27509. 517 Phone No. (919) 733•T015 ext 566,
Fain °wit,e
Rey. T106