382306_Well Construction - GW1_20100408

RESIDENTIAL WELL CONSTRUCTION 8ECORD
North Carolina Department of Environment and Natural Resources. Division of Water Quality
WELL CONTRACTOR CERTIFICATION N
1. WELL OOON�TRACTOR:
T►tAtdKlE L. OI.We(L
Or a -q—
el
snap
STREET ADMEN (9L)4 (f et.t.w
Moor to etc, 2 u 2,
Clt�' y or Town tat. Zlp Cato
t �c4 4 1104 togs ..
moo ► h
& WELL INFORMATION:
SITE wEU, ro Msscpaoapka)
STATE WELL PERMITS('a��)
DWQ or OTHER PERMIT a(N appao�)
Io-21
• Wall USE (Check APPEoeble Boor): Residential 1Weter SuPPIY
DATE DRILLED -10 NANA Pt i? ONO
TIME COMPLITED I 1 "OD
AM ay PM D
S. WELL LOCATION;
CITA L3Nl11a COUNTY U Nto r,
%log fizovibe?..ce Re . SoiAN
TOPOGRAPHIC/
LANDSETTING:
(o9/000 W w wag• D other
refry!**
LATITUDE �° 5 . 123 a
LONWTUpE ji .Q° 41�w
Latia'd°/10n1("de moo: 'OPS DTopogrophic mep
61:colbrolordmoottm aho,m on E C MOS tope mop end
iledbtit Ib►mInof ushp GPS)
4WELL OWNER
OWNin NMI
STREET ADDRESS
A.g.AAw
Vaud
k+i oos3i
1' 114e WEl tE
8309 �odyo�EAre (�. Sownt
State
`i3- 32't
• or1l none w
a WIC SWAM
tee TOTAL DEFTER I
b. DOES WELL INFLAME EXISTINO WBLL7 YES D NO De
s. WATER MIL UNowrTcP of Cooing: 35 FT.
May be in *pen,
minutes, seconds or
Ins decimal Amyl
pre /Apr.' Top d Casing)
d. TQF OF CASINO q ( FT, Above Land Sunoco'
'Top d Nam tom J Iona surface mar nqun
•wrIonolh aooadattps with IM NCAC 2C ,0110,
0 IVO (gp, Tr•- 2-5.... METHOD OF TEST ffi2
1'11
Zip Cods
a11,�1s�'C�
3 (J cti °
I. DIStNPECTION: Type '1D`lo lurk
O. WATER ZONES (depth):
Frorn......0_ To___.__.
From_
From- 2. To
I. CASINO:
From,
From,
F►om.
From O Depth ! 2 ( Ft. I�rr ate
From To
To Ft.
To Ft._
Amount lip oZ'.
TO
To
To
TtMobNssr
Soltt i t X2
T. GROOT: Depth Woad
From[ _ To 3 Ft. PRruu4e.
To
.,..At
From . 3 # Ft. aevrov1TE
�.. T Ft.
S. SCREEN:
From
From
From
Depth
To
To_
_ To
PrMOW
y
rrmP
Diameter Ste Star Marti
FI. In. ......_ h.
FI. In. In.
Ft. In. h.
I. SANWORAyEL PACK:
Depth Size Melsr41
From ToFt..___._,
From To Ft._,__�
From To Ft.
10. DRILLING LOG
From To
0 '
65 aS
45 Ito
110
ISO
I1. REMARKS:
Formotbn p
REIN cited' cg:
8R-4:w►• i OW
al.owN CAM( %ROC4
62000 514At4i2oc
APR 0 8 2010
Inforrriat:i”, e., .__. ..
DV+OQ,/BOG
DO 1RREIY CORM' MAT ON WELL WAS cONNTRIXOND sOCCONCIIIMttl
iH NCAC ?C. Wail CONSTRUO11014 STNIOARCS. AIO TINT A COPY OF IRIS
RICORD NAI IEEN PROV10E0 TO WE WELL OWNER
---Mr
11-100444 L. OL1
PRINTED NAME OF PERSON CONSTALCM TFIWEU.
Submit ths MOW to the Division of Water Quality within 30 days, Attn: Information Mgt.,
1017 Mall lsMci Cutter- Raleigh, NC 27599.1511 Phone No. (919) 7334015 •xt sae,
For 9_114,o
Rot1100