HomeMy WebLinkAbout383750_Well Construction - GW1_20100521ICEc
1. WELL oatTRACTOR1
1'RANWE L.OL /eQ.
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ama
STREET ADDRESS (otoltJ MetNu., 04.
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a TOwn tate
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aoo� n
t WM. INFORMATION:
arts WELL IDM veM)
STATE WM PERMT!I;e )
DWQ or OTHER PERMIT e( „ppposbie! 10 -VAILlol
L I*l ( AFploaDi. Sox): Reolvotiat Water Supply d
221
ip Code
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TWE COMPL D S .00
a. WELL LOCATION:
CITY: t)e imo/v
/0 gEr ..
TOPOGRAPHIC/ IAND SETTING:
De* OM./ Sthet ORldpe Galt OOther
LM1 UOE _a5 a o i. toog
LONOtTUDEU Oa Lk. 24= W
LatitudMonsitub source: tiOPS OTopognphIC "CI
ttimbtohtihnnof shown on • u$O$ typo mop rid
Maa+fndtoll* ib roInot ushp GAS)
4 WELL 044131
120R (noo(LIE
STREITACCRESE
Akira ,•Nc
0fown
Toy
& WELL DRAIL*:
a TOTAL DEFTN: 25
b, poet WILL RtIPLAO1 rite WULL? YES e( NO o
o. WATER LEVEI. kw Top d CNN: I FT.
oho' 'Above Top d CNlnp)
d. TbP OF CASINO NI•
1 FT. Above Land WNW•Top d h^^ vw land surface may racNIni
aWrothReordinoe WM 18A NCAC 2C .0110,
yr YNRD (W+mi... METHOD OF TEST AIR
AM O PM se
COUNTY t t-iI o
May be In terms,
minden. Noon* a
Ins deehnel Meat
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RESIDENTIAL WELL CONSTRUCTION RECORD 3 S 3 7 5 0
North Caroline Department of Environment en0 Mum! Resources. Division of Water Quelhy
WELL CONTRACTOR CERTIFICATION N 3002 A
f. DISINFECTION: Typo -10' / 1411‘
0. WATER ZONES (depth):
From— T From 2.27 To
From b 9 - To___ From To
From 2 p$ ToFromTo,�,��
O. CASINO ThloloISav
W MetuW
Sp zt PVC
loot.
Fran O
Fran_
From
Dtemetor
To 43 Ft._____".
To Ft.
To
Pt.
Amount
T. GROW: Depth Maoris,
Fran,_ To 3 Ft. Po27"i.Ar6
From 3 To 1At Ft. C3EN )P.ITE
irrom__„_,� To FI
0. SCREEN:
From
From
From
Depth
To
To
_ To
f, SAND/Ott AVEL PACK:
Depth
From To
From _.To._, ...
Fr To
10. DRIU.INO LOCI
From To
31 255
AMStoti
ouR
Diameter Sat Etas Moil
l
Ft. In. h,
Ft. In. h.
Ft. In. h,
Ft.
Ft.
Ft.
elm World
FommEon Oeso tbn
Pet. etigy
j3 (wog SANli
/Sum (RA+41 rr
MAY
11. REMARKS:
information Processing Unit
I DO ISM coml. TWIT TISI IMIU. WAS CONITIIICREW NAOOOIIOA110I ISM1
SPA NCAC IC. WM CON$TIIUCTION rTANOMtoS. AID MAT COPY OF INS
RICCRD I.$ NIN PROVDEO TO THE WM owNER
5--11-h?
•
Nu tE L. O1-J6 L
PRINTED NAME OF PERSON 0010111=441101WELL
811bMi the original to the Division of Water Quality wIthin 30 days, Attn: Information Mgt,
Con* Ratsigh, NC 2709S.1011 Phone No. (919) 733.701 t1 •xt 504.
Fa11ri • by, • •
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