383436_Well Construction - GW1_20100513

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RsSIPENTL4L WELL. CONSTRUCTION RECORD
North Carotins Department of Environment and Natuni Resources. Division of Wow Qualhy
WELL CONTRACTOR CERTIFICATION f
1. WELL OONTRACTOR:
RANr con, W E L L wee-
W.
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tints
STREET ADDREOs CAM Pneju,4 (,
p-i#46 NC- 2StIZ
�M or Town State Zip Cod.
c 7O 1 } 1uM &oas
I. WELL PPORMATION:
t31TQ WELL ID ttprapplbsd,.)
OTATI WELL PERMIT , )
OWQ a OTHER PERMIT opr apoocoo e)
10^y4
WELL t*E (Chadt App(e Box): Residential Wader Supply D
DAT"ORILLSI 'irk zg -Id 1Q.((6A9idr 0
TWE COMRETID. 3 4p NM o PM (' r
&. WELL LOCATION;
CRY: l43A,c1440 COUNTY UN
01 ep-try.
TOPOGRAPHIC/UM SETTING:
Cops' C ply DRRidge 0Other
Medi vetoed* boa)
° r be in tisrosk
TRUDE .� 5 .3 . D R 2 N minutes, ma* a
LONGITUDE 1g 0 • 55 o in a decimal Murat
t d : I 'OPS DTopopiph(t: mep
dac'hed to tit Anm / SI►ON n on • USGS hypo map aid
4 WELL OWNER not Mpg OPS)
OWNERS NAME 1.A&
STREET ADDRESS .J001
�� Il3
a ortAf t�s Zip Cods
^tw Ood1 • f)on1 h
WN
S. WILL DETAILS:
L TOTAL vent 4 551
b. DOES WELL REPLACE EXISTING WELL? YES 0
LEVEL
(UMWNAboetr Top d Casing)
ELT F OF CASMO p 1 FT. Moe" Lend Wpm'
`Top d bN
col% Wier ow WV ludic* miry requite
mimeo* hWoOot mph IBA NCAC 2C .0118.
0. �(9Pm1:— 11- METHOD OF TEST i4R
NO
o. WATER CONN, d Cuing: Zo FT.
y
3oo2 f1
3"3�
1, DISINFECTION: Typo ?0 °]o 41T14 Amount
0. WATER ZONES (depth):
From 21O To,
From To,
From— &_0 To,
S. CASINO:
Depth „
From O To 4Q Ft. (o'i8'" WSA(L al
From To Ft.
From
To Ft.
7.OROVT: Depth
From._. d To_3 Ft.
From 3 To 2o' Fl.
From_. To Ft.
S. SCREEN: Depth
From To
From To
Prom To
b. SA GRAVEL PACK:
Depth
From To Ft.
Fran
To Ft.
r
To Ft..
10. DRILLING LOG
From To
O (D
(0 14
2
2
11. REMARKS:
32- o'1.•
From 31oo To,
F►omTo,
FromTo,
Thickener
Pic
PMulfol
i.14
Diameter Slot eke Material
Fl. In. Si.
FI. In. In
Ft. Vt. In.
Site World
ForsttltlDonxlptbn
Now
SIN al(Ix
. SAND16Ri14,EL
Gib
MAY 1. 3 2010
Information Froc5ssinq Unit
urriaJOUU
100 WRIST WRIST MAT MO WILL WAS CONSTRUCTED NAOOOIIOAICU WITH
1SA NCAC IC. WILL CONSTRUCTION STANOARCS. AIO TINT A COPY OF RM
RtCORO KO SEEN ►ROVIQSO TO THr! WEII OWNER
810$ATUR 54 -10
41A14-1a; L_ ot-k vet
RINT 0 NAME OF PERSON CONSTRUCTING THEY&
8utmn the OrlgInid to the Division of Water Quality within 30 days, Attn: Information Mgt,
101M tarp SSWlq 41111r_ Raleigh, NC 27599.1517 Phone No. (919) 733.701E ext 6a0.
Fain(' y11,8
Roc MO