382307_Well Construction - GW1_20100408

RESIDENTL9L WELL►i$TRUCTJON BXCORD
North Carolina Department of Environment and Natural Resources. Division of Water Quality
WELL CONTRACTOR CERTIFICATION II 3002
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1. WIEJ. CONTRACTOR:
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STREET ADORES! Lao ‘Li Mutoi. �.
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L WELL INFORMATION:
SITE WEU. DR"opoftema)
STATE WELL PERMITS(' awe_)
DWQ or OTHER PERMIT IRE oppscebh)
Cam
10 2.io
• WILL WE (Cite:k Applicable Boor): ReeIOentiel Wader Supply Er
DATEMusD 3-iq-
TWE COMPLETED -7: 30
------- AM 0 PM Qf
3. WILL LOCATION:
CITY: COUNTY (Ammo
5105 b,Asr4
a )
TOPOGRAPHIC / LAND SETTING:
1314e. OW* [Midge MIN,
opmedoNbed
UITIUDm j_ S ° 0'1___ 45g_
LONOIUDE $ $° Zi • Us
bittlude/longitvio scum ®'OPS OTopogriphic map
• the b Kiweit aata sown on. CMGs topo map and
ached to Ns Evnt/not mg GPS)
WELL OWNER
OWNER'S NAME _— A L�r ►ZM.. o Ott
STREET ADFJRtn 5 l S Dus1,1 lsu •,•.•__ •—
MARSkv►u,F u Zito
a vr.t Sta<e t� code
1 221e- n 2 uw OO�Oa r:a� ntlfrlpM
May be In deans,
minutes. wounds or
In a declmsl brim
WILL MINA
a TOTAL DEPTH: lop'
bDoes WELL REPLACE EXISTING WELL? YES 0
a WATER LEVEL BEbwTcp or Casing: 35
awe M Abow Top d Casing)
d. TCP OIF OAI1NO p 1 FT, At>oN Land Suffice'fop d � ism d►a�beim land .urteoa m r requln
avalence h e00°r'danoe tAM ISA NCAC 2C ,0115.
a Wllb (gPlnr METHOD OF TEST -
NO®'
FT.
1, DISINFECTION: Type 10°%u Het)
0• WATER ZONES (depth):
From 3 ,yam To
Fran 500 ' To
From (v73 To__�_
O. CASINO:
Fran O Depth 1 3 Ft. 'tar)nat'ar.
From To Ft.
From To Ft.
1. GROUT: Depth d Matut
Frorn,a_ To 3 /�
Ft. i"oa.Tt.AWd
FF ..._ „ To 35►- FL BE -Pro r,i
Fran,+. To Ft.
Amount
FromTo
FromTom._,
FranTo��
Thloiotaaw
Weight Material
e. SCREEN: 'Depth
From �� To
From To
FromTo
O. SA GRAVEL PACK:
Depth
From To
From ToFt.
From To F.
10. DRILLING LOG
From To
0 5
11. REMARKS:
MOW
P•ow&
PAP
Diameter Slot Ste:. WW1
Ft.. In. In.
Ft.
Ft.
Ft.
In. h.
h. h.
Sit. Malar4l
Form.tbn r • - • •
.16Row. pair (LnCAL
(3a is Si4pre
60-0W N Poo*
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LD g r r"r.
Information Processing Unit
1001ERIRY GIMPY THAT Tlee WILL WAS cONSnWCtW NA000110NICI INN
11A NCAC IC. WELL CoNsm uci1DN STANOMOS. AND THAT A OM OF 11M
Alcatel Me Fun into notO To The WEU.I OWNER
t'KAtJRUE L.. Ot,W64.
PRINTED NAME OF PERSON CON$TRUC11N3 WALL
Submit the original to the Division of Welter Quality within 30 days, Attn: Information Mgt,
1011 Mali aria Center-. RII.Igh, NC 27599.151T Photo No, (919) T334015 ext 539,
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