384547_Well Construction - GW1_20100615

3 4547
RESIDENTIAL WELL CONSTRUCTION RECORD
North Caroline Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION
1. WILL T'RAOyORi
R-A
Wal Con4aCia �) Name
sm.
STREET ADDRESS (OI41 Y (fl U.+ R .
MNc
�co0o•} rOwn -ato
ntw
Trane num M
e. will INFORMATION; .
SITlt WEtt ID tl(Sepolk, )
STATE W'aECL > SoPPfloaON
OWQ a OTHER PERI1pT IFO epppa ) 11) - 85
WILL USS (Malt AFpooebi. (loot): Roe Worrnei Water Supply 63'
DAVI mum
TINt CCNPLItTEo_.12.00 AM 0 PM G?
0. WE LOCATIOMt
CRY: t'nF1(Lswilt ,E COVNTY 11 11or+
28i z.
tip Codo —
TOPOGRAPHIC l LAND SETTING:
Weds Rrpgrl * ial* Creek Sinot OM* Other
%Amtrm .aL �° 2loo„4
LONORtJpg $ Q° 23. 3�Lath..
Anson sitok scum: �0P3 O TopopaPMC m.p
AtilibM hPd l ibm hown an . V$G$ topo mop atWRY ►D PPS)
4 rI
Mari NAIVE
STREET ADDRESS
May be In depress,
mirutu, moors* or
In a deolnte' Remit
t to ZIP
("�), 2.2t-292q
i� WILL DRM.SI
III; TOTAL WPM 2 50 t
b, Doss WILL.WW1 OWINGWELL? YES D NO t11'
II, WATER W1L kavTcp d Caring: 30 FT
(UN'+' /Atom Top d Casing)
TOP O CANN IS 1 FT, AAor. Land Surtaor
ash; kif' affor iarld Wow mry Wk.
'V11111+00110o«ano.wror IM NCAC 2C .0110.
MD OP* ZO METHOD of TEST Ala
3o0ZA
1, OLINFtCTION: Type 70 '1014M11 Amount
.. WATIR ZONIS (depth):
Fran, To
Fran_ To
From To
O. CASINO:
From 0
From,
From
From,
From,
From
Depth Demean
To yW Ft. &. 'OR"
To Ft.
To
Ft.
t0 oz.
To
TtL
To
TNohneerWNW _
7. GROW: Dopth Mato W
From To 3 Ft. Po(k1.A144
Fronw,_3 ,To_35+ Ft, 6EN'Svr.1rs
From � Tom, FI.
O. SCREEN: Depth Ohmmeter Ste WW1
Fran_.,. To.._,. Ft. In. h.
From To Ft. In. - h.
Frorn To Ft. ln. h.
F, SAND/GRAVEL PACK:
Depth
From To Ft
From To Ft
Fran To Ft
10. DRILLING LOG
From To
0 2.3
23 2So
11. REMARKS:
size JUN 21.111012
Formdon Daaiptbn
Rs � maxitzoc
6L.44 Sri /6(440.71.
JUN 1.5 2410
"'"ItliPrrtelttiOn Processbm
va
I WIMP CIIRTPi THAT TIrO WILL WAS COl11fla)C110 N ACOOIIOAMO! 1MM
iH NCAC Jcc. WILL CONSTRUCTION STANDARDS. NO TWATACOPYOFIRS
!ICOAD rW stem ►Rovioto To TM Wtll OWNER
1-RArlAc1E 1.. O -\ 1t.
PRINTED NAME OF PERSON CONVRIMMWELI.
Submit
to the DI'vi:lon of Water Quality within 30 days. Attn: Information Mgt,
spa Cot* Raleigh, NC 2759E-1011 Phone No, (E19) 733.701511xt 550,
For Trip
Rot?110066