386366_Well Construction - GW1_20100817

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Caroline Department of Environment and Nature) Resources- Division of Wets► Quelhy
WELL CONTRACTOR CERTIFICATION N 3C0z. A
.WELL OONTRACTOR:
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Wel Contreola (hdi Name
C-RROLt�A Et.� 172:t+a rn
Well Cotltactort ompert1 Name
emu ADDRESS to1D14 RR R. _
NioN�G
CMyerTt7wrt`�"btateNC Zip $did_
L WELL INFORMATION; .
SITE WELL ID tip mo:sow
STATE MIX ate apPitoFota)
DWQ tr OTHER PERMIT Pm aPPacabie) l O - 05
WELL USE (Chock APpIable Sox): RoeVOentni Weiler Guppy Cd'
BATS MIm SD 1-23-10
Tt13 tcoNPL/TsO =00
a. WILL LOCATIONt
CITY: A4114)
Si ohs
AM CI
PMtli
COVNTY (Artor
TOPOORAPHICILAND SETTING:
DNcpa• OVINE efFM wimp pother
WWI prpoplewboa)
LATITUDE 3 4 S3.52(o l�
LONW IC 9° 5. 58b w
latiAlddla lt+ldo Po oo; BOPS OTopographic map
• 11oelboo►•MImwte• shown on • VSOS topo riwp Ind
a(EEhldbrlkt Ibrm TIIoI (nhg OPS)
4, WILL O'IM01R
oWP 'O NAN E au tit Eut t is EP4
STREET ADDRESS .,� D . BoK 3108
LcActilth, toe_ 211113
own . ztp
2124
liters o • Phone nunk w
',WILL MAILS:
a TOTAL DEPTllt q5o'
a DOMMWILL REPLAN =TINO W5%.L7 YES 0 NO Qf
a !ATR LIME INbwTop of Cooing: 33 FT.
owe If Above Top d Cooing)
TOPOP CASINO l5 1 FT, Abore Lolrtd Wm'
'TW d CNN IlirgaiarWgirret lend *wham Tay rtpuN'
Iwimps h /000rd. S WM 16A NCAC 2C .0110,
, Yap(ePn* ID M1T1100 OF Te5T ''-
Ms,. be In derma,
minim, sew* or
Ina decimal Wilt
1, DISINFECTION: Type_
e. WATER ZONIS (depth):
From $70 To Fran,
From ' To From
From To From,
3 6366
d31-__ Anwmm 44oz.
To
To
S. CASINO: TAIOateeN
°epth Detester Weight To_ 4s o f MO,
O To Ft.
Fran To Ft.__. ....--
From To Ft.
T. OROVT: Depth Materiel
From10 To 3 Ft. r Lic.""
From 3 To ?. CL FI.
From To Ft.
P. SCREEN:
Fran
From
From
Depth
To
To
To
Diameter Slot Ste MINN
Ft.
Ft.
F1. In, in.
0, SANDIORAVEL PACK:
Depth Slse Melilr
From �._To.._.__ Ft.•,._....
From TO Ft.._,,,,_
From To Ft.
10.DRUM 1.00
From To
0 1
9 So
11, REMARKS:
Formotbn DocrIpdon
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69.11,01*
Ana Pint .
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:o w 1
100 IMP CURVY TriAT De Well WAS O011S1mC11D M AOOOl0ws vim
ISA NCAC Ic. WIL100t4$T11tAT10N VTAMOA*OS.OMIINTACOPY OF11e1
RICOOID tW 11I1N PRO VI0 TO T1ft wow. omen.
�KROwE I, . Ouve(z
ORINTED NAME OF PERSON CoggiMialNWELI._...
Submit the °right)tothe Division «Wow QuaIlty Within 30 days. Attn: information Mgt.,
1017 MsN kr** Con*- Raleigh, NC 27599.151T Phone No, (919) 733•T015 ext Dias,
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Ran.1106