383775_Well Construction - GW1_20100529

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I. WELL INFORMATION: •
SITE WELL ID ATsoolkoot.)
STATI WELL PERMIT/(Iappfto)
DWG or OTHER PERMIT INN appSoopW)
01) W1c:/i/1
RESIDENTIAL WELL. CONSTRUCTION RECORD
North Caroline Department of Environment and Natural Resources. Division of Water Qualhy
WELL. CONTRACTOR CERTIFICATION N
1. WELL OONTRRACTORt
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actor Company N.m. •
STREET ADDRESS (94+0 MEt.Lt., f Ly
MoNane
i. WELL =ATI0
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COUNTY UNtoa
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WELL Ws (Cheep Appleeible sox): R«IOentiai water Supply 0
DATE OPIUM 5-P I-10 IWtiop-lo,+ 0,4_4
TIMIt COMPLETED 5' 30 /uy( O PM p'
May by in dress,
minutia. seconds or
In it decimal Snivel
S.WILL O im
ITS NAME Etj6
STREET ADDRESS 1221S (. Sob t
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4 } 7(03- 2214,
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113
aweLDITAIL$?
a TOTAL DEPTH: 55
b, Dols WnL RlPtACE worm wELIT YES p NO r�
a WATER LEVI. SIIowTop of Caring: 25 FT.
Pew FAWN Top d Casino)
d.. TOW CASRO IS FT. Abwr Lund Surfror'
'Top d Dating NrIt Wcw Irra rurfuos mry naukt
a in:e h smadincovfltti 15A NCAC 2C .0116,
a MU) 5n METHOD OF TEST t R
3a 2 A
f, DISINFECTION: Type
e. WATER ZONES (depth):
From 510 To
Fran 9 3 ' To
Fram__O To
1o° o ihH Amount oZ
From
Fran,
From
0. CASINO;
From_ O , To_Z_ Ft.
From To Ft.
Fran..,.-.._ To Ft.._��
T. GROUT; Dopm nMutordM
From V To 3 Ft. POR-%IIVA
From. To...al.' Ft. r,.no„trE
To
To��
To
ThbOneW
Weight
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Msg. z
From To Ft.
0. SCREEN: Depth
From��- To
From To
FromTo
t. SAND/tiRAVEL PACK:
Depth
From To._._. Ft.
From To Ft.,
From To Ft..
10. DRILLING LOG
From To
0 /(,
No 29
29 155
11. REMARKS:
ROW
Diameter Slot tame Malaw
FI. In. h,
Ft. In. P.
Ft. In. R.
SIN World
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DD RIM GIMP* ?RAT TlQWILL WAS CO,I UC1IDNADO0RONIOIVON
. 1101 1 CJAC IC. Will OONr r u0T10N STANDARDS. MONO A COFY OF 11M
RECORD Wts FEIN MIONIDtD TO 11re WELL OWt4 . •
5-1-1- to
weu OONTRACTOA 'T
ORINTED NAME OF PERSON COT4S1 RUC 1NG WELL
1 the
original to the olv�lon of Water Quality within 30 days, Attn: Information Mgt,
�vla Canter- Raleigh, NC 27590.111T Phone No. (919) 733-T015 eat 6615,
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