382532_Well Construction - GW1_20100416

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It, WELL INFORMATION;
EMI WELL ID for oppowitd.)
STATE WELL PERMITa(r )
DWQ or OTHER PERMIT 10(a applicable) 10 - 2.1
• WELL UBt (ct,.c APpiaible Box): Residential Water 8uppNy 0
DATE mum ' i- 2- 10 I RA GATIoa O NIA
AM PM(i'
TIME COMPLETED Itoo
s. WELL LOCATION:
CIT' WAle ,.,
13oo S 1 dEc 64.. 144.
TOPOGRAPHIC/LAND
Webps OVollw SETTING:
t of ° l ootf>,r
�Pprspdata
LATnUD* .L. ` � 59.
Lowerrup Fi 0 ° so. zits &
COVNTY U,+`oN
Msy be In dorms,
minutes, No * or
Ins decimal Ibrtnst
LatitudeAonS(* source: @j o0P3 T graphic map
ilkstanCfse/ nttgtbe therm on a USGS tope map and
MfeshedloMllr Awn no mg GP$)
4 WELL O eR
STREET ADDRESS 3Oo SF•FImo ECoOs_ Lei .
LOAKHAw t C.
Of Stet. Zip Code
tom* 241- 3511
^�'�a �0d0.
5,WILL MAX*
L TOTAL Sint ZOO
th oyess raw. RIFLACI lD1ISTINp W5U..? YES o NO 21
a WATER LttM Sob" Top d Casing: 25 FT,
(Uss • If Aboaa Top of Casing)
TO OF CAMEO p 1. 5 FT. Abort Land Suring'
'Top d cub, M oNar b • land mho. m.y Muir•
mimes 10A NCAC 2C .0115.
YI D WPM):.....2.5 + METHOD OF TEST AI (L
211113
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RESIDENTIAL WELL CONSTRUCTION RECQRD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION If 300E 3,2532
f. DISINFECTION: Type '10% I+n4 AMOUR' Ito 02.
0. WATER ZONES (depth);
From 90 To From 13c To
From___23_:, "To1 From /�loS To,
From Il0 ToFrom To,
0. CASINO: Thlolotastt/
Depth D WNDht
From O To j�s Ft. Lo' . Sp�2i
Fran To Ft.
From______ To FL__
T.OROVT: Depth
MOM
Material MONO
From•.._0 To3 Ft. PotLi't.ANII §(.24-
ToFrom3 Zoo Ft! 'Qc' Mrre Ame
From,+ To Ft.
I. SCREEN: Depth
Fron��. To
From To
From To
I. SAND/GRAVEL PACK:
Depth
From To__•,_
From ToFran _^
To
10. DRILLING LOG
From To
0
I ii'L
)12 200
11. REMARKS;
01 nnler Ste Moo Motorist
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Ft.
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Site World
Foetlon Dtaorlptbn
BfinROWN CLA`I
B{towN . i'A -yo iE /G9.4wEt.
RR04..' f & we 6e.ab rrE
RIME 6(14,0 tTE
I it" r9AIr"^'r:
A rdi 6 2010
lrttorrnation Processing Unit
DWQ/HOG
I DO WEST CERTVY TINT 11E11 WILL WAS CONSTRUCTED IIPOCCIMAIIN REM
IRA NCAC IC. Will CONSTRUCTION STARDO *a. AIA 1INT A DOPY OR 110
RECORD 11A$ SEEN MONAD TO THE WILL OWIWEII
CRApILAt t,_ otA.Je(L.
PRINTED NAME OF PERSON CONSTRUCTING ?NE -WELL
Submit the min! to the DMsion of Water Quality within 30 days. Attu: information Mgt,
1$171411R Wes COOS-, Raleigh, NC 27699.1017 Phone No. [phone] eat 665,
Fatlli 71,a , ,
Rar.1106