382801_Well Construction - GW1_20100428

1. WILL CONTRACTOR:
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WELL INFORMATION:
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STATE WELL PIRMITB(s ate)
OWQ a OTHER PERf1IR opt applicable) 10 -1 o
• WELL Wt (Chock AMMON Emq: Resldent:el Water Supply 3'
DATE ORILU -1-15 /0
TWECOmFLaTap 3'00
i. wait LOCATION:
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COUNTY U�tov
29st &2c g /11.114, LN.
TIC / IAND NETTING:
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%ATITONE 3 5 ° oz. 56,2m
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O. WELL MAUI
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C WATER LI M, BII0W TO'P of Casing: 20 FT.
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d. TOP OF QUM I$ 1 FT. Above Land Stem'
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11, Yap ter---._ METHOD of TEST A'Q
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RESIDENTIAL WELL c QNUCTIoN RECORD
North Caroline Department of Environment and Neural Resources. Division of Water Quality
WELL CONTRACTOR CERTIFICATION N 3002A
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I. DISINFECTION: Type_
0. WATER ZONES (depth):
From__112_ To_,___
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O. CASINO:
0% Amount, ((e o2.
Fran �Q Depth_ 51/ Ft, Di
From_ To Ft.
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7. GROUT: Dom Matsrlel
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O. SCREEN: Depth Demeter Slot Otte
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f. SANDf RAVEI, PACK:
Depth
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From To
10. DRIU.ING LOG
From To
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11. REMARKS: p"bO,.
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I Do MDT CIRTP THAT 11a1 WE WAS CON/1RN0IE0II A000IIOAMCI !MN
tM NCAC IC. Will 00risTRUCTIDN STANDARDS. NOWA!ACOPY OFIIM
NICOND MA$ StlN PROnotO TO THt WEII MINER
grJtelE L. oµµJ
PRINTED NAME OF PERSONC4OTRTRUCtINO tHEWEti
$fin the original to the Division of Water quality within 30 days. Attn: Information Mgt.,
1017 Mili service Center- Raleigh, NC TTa49.1617 Phone No. (919) 7334016 ext 699,
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