386165_Well Construction - GW1_20100811

R�,IIDENTIAL WELL CONSTRUCTION RECORD
North Caroline Department of Environment end Natural Resources- Division of Weer QYality
WELL CONTRACTOR CERTIFTCATION N 3coz 4_
1. t1YELL OONTRACTORt
Ouvea
VUdcattreoia Name
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STREET ADDRESS
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S WELL N'ORMATION: .
ilTI WELL 10 oR epplicom.) _
'TAU WELL PERMTIS(p..r ..ale)
DWOaOTHER PERMIT PR sppoosoN) /o-i17
. WELL Ufa (MO ApPaabN Ooor): Reeldenttai Wets! Supply d
DA711o11aLED 7-21-Io
TIME OOMPLETID / 3o AM D PM liY
&WMLL LOCATION:
CRY. /db,Ai TRAM, covNrr VtN�oN
WOO giAmcf4,40 Ci2ccc
TOPOGRAPHIC/ ANDSETTING:
°Mpo DVI*/ 13 M DRidpe DOtter
Mods sppeordom box)
tanUDE ,T, 5" O2 .4tI N
LONGRUDSI 0 ° go. ?4,3 W
Latitadelonsitudo num; Sf OPS OTopographic map
Nettntdllwmust b► sham on • VSO$ typo mpg WP
viM+Mdb tab km, nOttatrpGP$)
4 WELL OtME(R
OMtNERsNAir19 ri /i*.. tit-aMAO)) Ewz
STREET ACCRUE 2 207 -Fiott,,tt, L L.
(.o Eut.•6 28031
CIt►a inn • • Stet* Zip Cotes—'
Virkt%o -�121
AMraii oop0�� • Plow number
IMMORTAL*
v. TOTALDEP1lb 405'
b DO R WILL RQLACE EXI:TIND WELL? YES p NO t0!
O. WATER MIL /dowTop d Cooing: IS FT.
(UN'+' 1 AbvtRl, Top of Casing)
d•. TVP OF CA NG IS I FT, Above Lsrld Sufha•
'rood tlNtrg *minded odor blow land surhos mry Muir,
*moo ha000rdrgotNM 15A NCAC 2C ,011e,
YII LD Wm): 1 M5TH00 OF TEST MI-
1
May ba In doyen,
minutee,aaoonde
In a decimal Won
lay (41c/nC
386965
f, DISINFECTION: Type 7o % Fh71 AmoaA
p. WATER ZONES (depth):
From_ / $ 7 , Tom., _ From_•,_ To_�._
From 2r7 • To Fran
Fran__r To From,
0. CASINO:
From O OTofh 87 Ft. it �S
FranTo Ft.
Fran
To F1.
1.OROVT: Depth
Fran 0 To -3 Ft.
From,_ 3 To 25 Fi.
From To F1.
O. SCREEN: Depth
FromTo
From To
From To
1►. SANO1ORAVEI PACK:
Depth
From TO
FranTO
Fran To
10, DRILLING LOG
From to
0
To
TNobsoo/
SNIOM
AA
„MOM!
w.rP
Demeter Slot eke
Ft. In. h.
Ft. In. In.
Ft. In. h.
ito
'la
g0
11, REMARKS:
Ft.
Ft.
Ft.
giro World
Formation D,Stxtptbn
ro ale
rrnati
DWt liR sionum•ittet
DO HIIRM alltTlIT DOT T1AWILL WAS MAa00110"1"111
1 SA'CAC tcC,,. M u. OONSTNUOT1ON $TMIyARDO. OA THAT A 001f OF 11M
IUCORD I .1 HIS Mlt7VDtD TO TM Well OWNSA
PRINTED NAME OF PERSON emstRuctificiatu.
8ubmlt tht original to the Division of Water Quality within 50 days, Attn: Information Mgt,
1117 klvil Ionics Center- Raleigh, NC Z7649.1617 Phone No. (919)133•7015 •xt 505.
Fain TIPP
RN. MO