382533_Well Construction - GW1_20100416

1. WELL CONTRACTOR:
F�RItiLIE La L�vt'R
tr a ante
Cf1420LI1-1a We.
Or txrtpary Ntane
STREET ADDRESS tikoiik (104 a9
•
m0 aaot: N G 281 I z
o 1 Own tato Zip Cod*
-Bogs..
PnorlS n
t WELL INFORMATION:
ERE WELL ID RN efello p1e)
STATE WELL f'ERMfl11('applicable)
DWQ at OTHER PERMIT am apppo )
3. WELL LOCATION:
CI T: 113A%4ata COUNTY UNtoN
►�1+4:4+A 4E144-13. .tt 3
• ;7f'Tt�
TOPOGRAPHIC/ MHO SETTING:
0910Po Wart (t u* t Ut other
aa
LATITUDE J
LONGfUDE, 0° I. (0 5 W
Latitude/longitude source: WOPS OTopographic map
itcafbn,ofire/ matba shown on s USOS topo mop and
dichld MIhlt kint I not why OP$)
4. WILL CATTIER
OWNER'S NAME CyN- ml>� `T►o.�
STREET ADDRESS _�0, T3ac 431
Aikik4.1 01,dotate
Zi
.I�w oti00 I����� g • tlnrll
WELL WE me* Applicable 9oa): Residential Water Supply Se
TWE COMPLETED 12 00 AM O PM (W
Msy by In dooms.,
minutes,ssoonds or
In a dacinni Murat
S. WELL DETAILS:
a TOTALDEProb gOOr
b' DOES PALL REPLACE EXISTING WELL? YES O
WATER MIL BMDaTp cf Casing: 35
NNW If Above Top d Casing)'"""'—'
d,. TOP OF CASINO to ( FT. Above Land Surface'
`Top o1 cuing trntin•W aVorbNow hand suffice may require
• valence h a000rdancla wdh I SA NCAC 2C .0115.
a YIELD (gpn):•....a.... METHOD OP TEST f%rQ
NO(S'
FT.
l
RX/SIDENTIAL WELL COHSTRUCT[ON RECORD 3 4 6 3 3
North Carolina Department of Environment and Natural Resources• Division of Water Quality
WELL CONTRACTOR CERTIFICATION M 3002
f. DISINFECTION: Type 'iO°Jo i4i
0. WATER ZONES (depth):
From $30 T From__ To___
From—_70.____.__ From To
From 815 To FrosnTo_��,
0. CASINO: Thiolonsw
Var.
Amount 2 oz.
From Q
From
From
Depth
To TT1'3 • Ft.
ToFt.,
To Ft.
Diameter
£.o'fse"
T.OROVT: Depth Maeda,
From,. To 3 Ft. . PoRTr.A0A
From 3 To 35+ FI. a60-reH►TS
From Tom. Ft.
0. SCREEN: Depth Demeter SRI Sate World
From1� To Ft. In. In.
From To F. In. h,
FromToFt. In. In.
0. SAND►ORAVEL PACK:
Depth Slam Mabry
From To Ft.
From ToFt.Fran .____,
To Ft.
10. DRILLING LOG
From To
0 )�
ti* 21
Z\ Z."1
: j 4140
FormationQgow, Di RTOi2opwri
f3Uar G041 NYrr
Quaox2.
Q 60.t .,i
�rK1162010.A
11. REMARKS: Information Processing Unit
D WO/Rr,n
DO WRIST CI WY THAT Ties Wall WAS CCNftRNaTEDNACOIRLINCIIMIIN
ISA NCAC IC. WELL CONSTRUCTION STANOAROO. AMMO A COPY OF 111S
RECORD I4A$ PEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF ERTIFIEO CONiACTO t •
rKANS.IE L. DiAve2
PRINTED NAME OF PERSON CONSTRUCTING IMIWELL
Submit the original to the Division of Water Quality within 30 days, Attn: Information Mgt.,
151T Map Wake Center- Raleigh, NC 27599.1017 Phone No. [phone] *xi 565.