383751_Well Construction - GW1_20100521

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• WILL 110 ( Applicable Box): RwIOentiel Water Cuppy 2'
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DATEMum 5 //-/0
TIME COMPLETEDfr :30 AM O
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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Envaronmant and Natural Resources. Division of Water Quality
WELL, CONTRACTOR CERTIFICATION M :Oo2A
3 375
1, DISINFECTION: Type_
0• WATER ZONES (depth):
From 3 7_ ToFrom 13o To
from 54'1 To From To
Pram' To______ Frain To,��^
O. CASINO: TAIolotatll/
F_ Depth DIWTNter WI94 I2rN1
Fran To?� Ft. (v a/8 Sp2 Z! pVc
To______ Ft.
From..,_ To FL_
NTH Amount Lk) 02-.
7. °ROM Depth Material WOW
From 0 To 3 Ft. _ ,A Au_.
From,, To 35. Ft. FrThN irk.
From To Ft. _
O. SCREEN: Depth Dttamater Obi Sae Metall
From+ ToFt. In. h>
From To Ft. In. h.
From To Ft. tn. h,
1. SAND/GRAVEL. PACK:
Dopth Size Wald
From To Ft.
Frum To Ft._
From
10, DRILLING LOG
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I1. REMARKS:
Ft.
MAY 2 1 2010
1.•.in.m,N4inn Drnt•••••••:r..,
DWQ/BOG
100 HIRI1Y CatRTry TWAT TIaM Well WAS COIATIW01W NA0001101411MM
!IA NCAC IC. WILL 00NSTR6t0TtOOt eTANOAR0e, ANOMCA COPY OFan
RECORD MA$ SIN Fa0Y1000 TO TWO WELL OWNER
630
S
i'RINTED NAJ, E OF PERSON OONSTRORNMET411.
,h, A Witballt the s
10 the Division of Wow Qual ty within 30 days, Attn: Information Mgt.,
la fir- Raleigh, NC 27599.1017 Phone No. (919) 733•T015 ext 556, Rw.Tics