384548_Well Construction - GW1_20100615

RiSIDENTIAL WELL CON3TRVCTIoN CORD
North Caroline Department of Environment rand Nature, Resources. Division or Water Quelfty
WELL CONTRACTOR CERTIFICATION N 3oo 2 A
I. WELL CONTRACTOR:
RAN La
M . 2te a t./!y
MEET ADDRESS /olol&4 Meet i� P-a
E O Wt�R.
•rue
L3 . D
n9N�oE Ne- 281:2
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Am OOd► rumbtt
:. WELLINFORMATION;
SITE WELL IDMI,aa01i)
eTATT WELL PEA )
DWQ Or OTHER PERMIT tor applicable)
WELL Los (Chsc AMMON po: Roogenttei water euPPA' 0
awn! CR0.uD S- /9- io 64-rivA, orL y
TIME COMPLETED /2 oU AM 0 PM [�
a. WELL LOCA7101*
DnY: ��` ' COUNTY U'/o,/
IpC
22z5 Cabs gEgLf
TOPOGRAPHIC/LAND eETTINO:
CEbpo OW MtgeOOther
IATITUME J..L° 9. 21/
LONGITUDE 8
latitudeflonglexle
Fo/NNmwt ' RIMSDTvpographic mapitali
Maohod Ib I* Awn 1 mom on • UM tope ►n find
4 e tM ot D GAS)
W
OWNER'S NAME IL}N s, ,,6R
S REIT AMORO 2Z k,s
taw &Sy-5o95
^^1e�� 0001 • pIM D K
/O 53
tate Zip
May ds n dorms,
minutes, seconds or
Ins decime; ilormst
Nc- 28►73
"WILL MAUI
L TOTAL DPI* 550
b, Does WELL REPLAaE
ExtsMo WELL? YES 0
a WATER LML lobo Top of Cooing: 30
(Ww'.' NAtom Top d Casing)
d. TopOF awe ss / FT. Abu'," Land Sorrow'
?op d Ism ril land surfooe msy WAIFawillowIn aooar'ot'ro. + 15A NCAC 2C .0110.
( : 2 METHOD OF TEST r4i2
NO(e'
FT.
33454 8
I, DISINFECTION: Type 70% lftk Amount APO 02 -
II. WATER ZONES (depth):
From /o ToFrom 34f7 To
from 2 ? 70 From 3 95/ Tom,,,
From�go ToFromTo,�.,�
0, CASING: Thblstssv
Depth
FraTo 80 Ft. D / " S
n, 2/
From To Ft.
From To Ft._
7.0ROOT: Depth
�/Matertol
From, 0 To ¥ Ft._ / 02 i&s a is
Fran T Fl.
From,^ To Ft.
S. SCREEN:
From
From
From
Depth
To_
To
To Ft.
trulL
Pt4"P
a.neter eta Moo ull
r� Met
all
-lh•`:ct,
P. SANWGR►WEL PACK:
Depth
From To Ft,
From To Ft.
From Ft.
10, DRILLING LOG
From To
o
408 72
7 Z 55p
11. REMARKS:
Size
J1
C
Draw.' Direr
/3Row,� Cc.�i
r Roca.
6/Y7f'1
C
cur-15 7111u
inlonnauw, iroce iP1 Unit
DW Q/BO
100 EERpY CIS THAT no WRl WM cow MUCTIO N A000140.11011MMM
1M t$CAC 1C. WILL OON rrAtxr 10M $TANDAADS. AIO TENT A 00PY OF 11M
R$CORD MA$ 1ttN PROV4tD To Tilt WtU. OW111k
WA Alta- L. Quvt -
ORINTED NAME OF PERSON CONSTRVC 1N4 *mall
Submit the
1.11 to the Division of VYster Quality Within 30 days, Attn: Information Mgt,
S-2.N-lo
Center- Raleigh, NC 27599.1011 Phon• No. (919) 733.701 s •Xt 55Q,
RoY.1110056