383495_Well Construction - GW1_20100517

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Wear Quellty
WELL CONTRACTOR CERTIFICATION N 3 00 2A
3 J
3 95
ley 1(04 L SOS 5 . .
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L WELL INFORMATION:
SITE WELL. ID 10gippaoa ls)
1. W■LLOONTRACTOR:
Well Contractor p.me
O z i,J�l,l �R106.
Wd Contractor Ccmp.rty Nam.
STREET ADDRESS (cot4 ene t..1 t>,
• MO,►(LOE. NL 2$112
City or TOwn State Zip Cod.
STATE WELL PERMITON appoorrlla)
OWQ or OTHER PERMIT 141f applicable) l0 - 32
WELL USE (Check AMP ON Box): R.SlOnntisl Water Supply ('
DATE OmLLUDQI O
TIME COMPLE= 3 3o
S. WELL LOCATION
CITY: I.SA}cNAt4
(D(02 au7454E DO -
TOPOGRAPHIC! LAND SETTING:
DSlops OVdsr Ef FM _ oft* pother
(heat way** boa)
• t,ATITUDE
LONGRUDel,Q.
Lititudeloniftsdc: Li0P3 OTopographic map
• ( s0"011101M001 a MORT/ on s CSGS repo map srtd
MadNd(bNrlbrm'not (mkt GPS)
4 WELL OWNER
maws NAME Awsor, & No
STREET ADORNS (O(o2t( PI.o6u4E (L.
AM O PM Mr
COUNTY U4'Io►4
May be In deepen,
minutia, aoond$ a
Ina dealmel Mmet
rue 28►'13
own Stahl Zip Code
qo5- s8 9
rllOns flhl lbw
a WILL DETAILS:
a TOTAL DEPTH 2 55
b. Does WEu REPLAp4 al yren WELL? YE8 DJ NO
a WATER LEVEL CMowTcp or Casing: 30 FT.
(UN'+' N Abel, Top d Casing)
d TOP OF CASINO q I FT. Above Land Sunoco'
'Top d calm arm uUor b. kind suffice msr niquks
%grime h soeadtrloe Wllh 15A NCAC 2C .0110.
Mb (11Pn^): 2— 0 METHOD OF TEST fhR
1, DISINFECTION: Typo .70°% ►hVI Annum ( oz.
o. WATER ZONIS (depth):
From To____ From_ To
From ' ToFrom To��
Fran To from To
S. CASINO: T iolo sew
Dig
From 0CToth I0$ Ft. to rrIr MOON
St t FIPZ
IW
From To_•„__ Ft.
FromTo Ft.
7.OROUT: Depth Materiel Mothod
Fra+T._. 0 To 3 Ft. Po(ul.i*16 Pou R.
Fran S To 35+ Ft. QErstoratiE Pun.P
From^ To Ft. �..
S. SCREEN: Depth Diameter Sat Woo MOWN
Fran To FI. In. h.
Fran To FI. In. h.
From ToFt. In, In. ...��
0, SAND/ORAVEL PACK:
DRAM Size MeeO N
From ToFt.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
o g
IN
No 255
Ile REMARKS:
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Information Processing Unit
100IEMIT NATTY TWIT Tiw WILL WAS CONSMUO =11Ab0011SA11CSIN IW
ISA NCAC SC. WILL CONSTRINOOR STANOAROS. SKI MAT ACOW CFENS
MORO HAS NIH PRO CKO TO THE WELL OWHIA
REF CERTiFimo WELL CONTWICTOA AT
w.rtrsv-%E• i.-, OL, 3ea.
PRINTED NAME OF PERSON CONSTRLTC INO SWELL
Submit the original to the Division of Water Quality within 30 days, Attn: Information Mgt.,
1011 MuR lsMci fir- Raleigh, NC 27599.1917 Phone No. [phone] axe 569,
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