HomeMy WebLinkAbout382305_Well Construction - GW1_20100408tl, aaI 1A/1C
RESIDENTIAL WELL
CONSTRUCTION RECORD 2 0
North Carolina Department of Environment and Natural Resources. Division of Wear Quality
WELL CONTRACTOR CERTIFICATION N 30o2.
2$I 12
Zip Code
OR- 201
• t111t11 Litt ICheelt
API*1111 le eat): Residwrtlal Motor Sup* Gif
DATE DRILLED 12-i
TIME COMPLETED 30
AM PM(�'
STREET ADDRESS 11/ /►7t ,,
OogoC Nc.
tx over = tata
L WILL INFORMATION:
STTv WELL ro OIIreppNaaeN)
STATE WELL PE ,
DWQ or OTHER PEIMMT I(!► eppocoblo)
S. WILL LOCATION:
CITY: moaRaE
CCVNTY UJJiom
i -711 Sim W u I;rA,rr
TOPOGRAPHIC /Clop
SETTING:
Delopi. DVW/ Q' W DRRIdpo OOther,
Gall AVImPrImo
LATITUDE J. £ 55. 92 rui
LONGITUDE S a: z$1_
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4 Well OW?l R
OWNelt0 NAME A d- Am
STREIT ADDRESS1'111 S W'wiAmi 2n.
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oM) 2$ I12
Stab Zip Code
a Wml DETAILS:
t. ToTAI DEPIN . 21
b. OM WELL SEPIAS!! II aaMllrp WELL? YES D
R WATER LIM Bobo Top 0/ Cooing: 35
Pow 11Abort Top or Cooing)
d. TOP OFCAMS a
FT. Above Lind Suffice
`Top a mllhg bm tltlof b ow land iurt.oe m r roquYl
•"moth oxadonoo W M 1SA NCAC 2C .0110.
0, MD Wm):.. (o� METHOD OF TEST _ Agl-
May be in deploy.
minutes, aoond, a
in a decimal k,m.r
NO(e'
FT.
Submit the original to the Division of Water Quality wtthln 30 days, Attn: Information Mgt.,
1011 Mop Sevin Center- Rtltalgh
NC 2754E4017 Phone No. (E19) T33•7016 ext 660. FCIP19# 11 •
Rev. MS
D O O_ I Ft, PletiarvilftrItit"
_, • To Ft.�_
ToFt._,__.
7. ,)ROUT: Depth Motorist
Fran 0 To 3
Fran 3 To 35'
From To•_�
O. SCREEN: Depth
From To
From To_
From
5
I. 0181 FECTtON: Type 7Q U/cl'I Amount
6. WATER ZONES (depth);
o— From To
Fran 5 2lv
From Tom..
From To From
To
0. CANINO:
Fran,
From
From
Ft.
Ft.
Ft.
Thlolsnnr
Sbeat MOM
MONO
Po
Dlarnster Sat Sol MotwW
Ft. __In. h.
F1. In, h,
To Ft. h.
P. SANWORAVEL PACK:
Depth
From To
Fran
To,^
Fran To
10, DRILLING LOG
From To
0 to
_J9 2-►
11. REMARKS:
Ft
Ft.
Ft.
Sixi IAalarW
Q2ow Form:Form:don Doscdptbn
60D..4,J "DiRr /Ioc*
t7(Iota N co..
Information Processing utw.•
DWC.N.JBOG
DO IERt1Y ClRTpy TINT TIEii WELL WAS coristsugioNAOooIANC odd
IIA NCAC IC. Will CON*TRUO11ow STANDARDS. MOMAT ACOPY OFIIM
RICCRD )4A1 TEEN PROVIDtD TO THE WILL OWNER
WZ4Nitie L. o vet
3-2(v-lsyro
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PRINTED )
NAME OF t3ER80N CONS'TRUMNd't4WEi.l.