386367_Well Construction - GW1_20100817

1. W■LLOONTRACTOR:
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RESIDENTIAL WELL CONSTRUCTION RECORD
North Caroline Deportment of Environment one Meters! Resourew• Division of Wets gustily
WELL. CONTRACTOR CERTIFICATION N 3002 A
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Contreota Nome
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C.ZPUNA "DR-►u.1�G.
WaMoctor Company Nom
emu ADONIS Jot014 (Y1t'DUN I�b.
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L WELL INFORMATION;
sox wEU. ID Wreppees :4)
STATE WELL PERMIT W applioable)
DWQ a OTHER PERMIT INN applicable)
WELL USE (Chock ArgMoeblo 11;;O: Rsoldwttlol Watw Sup* tI
DATE OINLLeu 1- Z4 - to
TRWOOMPLETED 1=00 AM 0 PM e'
S. WILL LOCATION;
' LAAA144,Ata COVNTY LAPAO
lo(003 R40.0„1, i�EUNS Qe,
�uilbe�, CarertunIty. QubdWon, Lot No.. Tar )
TOPOGRAPHIC I LAND SETTING:
DSWS.OV iy NOW ORIdge 0Other
LATITUDE ,� t58
LONGITUDE 0° 110 W4W
Latitokilonsitede worm: i1i'OPS OTopogrsphic map
• Aositnerllehnestbo shown on . Vs03 (opo map end
MhoMd WI** Am, not title GP$)
Miry be In doaevo,
minutes, names Or
In a dsehral Mnel
& WALL OWNER . .
STRUT AMMO S0603 HEuas 9.
LANAt444,4NG 2,St11
City or Tam . • State . zip Cur—
( ). ` 11_-5o39
AINcode• Mae
&WILLMAR.%
TOTAL COT* 250.
booUSWW.LREPLAN oGSTINo WELL YRS 0 Nod
.r WAru LML OMowTop of Casing: 30 FT.
(UNw SAWN Top of Casinp)
07.. TOP OF CAPS 10 1 FT, Above tend tWrf,w
'Top d-I11110lent instid etor Waft lend surface mWf multi
• ;intone h eosadenoe tMth 15A NCAC TC , 0118,
number
o WILD (�IIx.... �..,. MSTHOD OP TEST_
f, OI.INPECTION: Type
p. WATER ZONE. (depth):
From /24 To
Fran 1� N 3 ' To_
From To_•__'
e. CASINO:
h
From 0 To L9q Ft.
Fran To Ft.
From To Ft.
7.ORDVT: Depth
From O To 3 Ft.
From_3To 35 Ft.
Fran_. To FL
1. SCREEN: Depth
Fran To_
From To_
Fran To_
6367
° o II'M Amount.. := Oz
Fran To,
Front,
From To..�.�_
Tbiabbeoe►
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To�—
MOM
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Domeier Slot Otte MOM'
Ft.M. It,
Ft. In. h.
Ft. In. Irt.
e, SAND/ORAVEL PACK:
Doh Was Mrerlr
Fran To Ft.T"_^._
FranTo Ft._.__
From To Ft.
10, DRILLING LOG
From To
0 11
11 5o
5o Z.co
11. REMARKS:
VI
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.ten Unt
I DO IAMBI Col M' MAT RO W!u WAS CONITISICEDNA000110.41011EM
ANOINT
tIA 'CAC IC, WILL CON$TRU0110N STNIOARDS
ADOPT OF INS
11ICCRD MIN P1tOWVID TO TM WILL OWNER
or
PRINTED NAME of PERSON ESNIMilnewat,.
St the otiphltd to the Division of Water Qu$llty wfhin 50 days, Attn: Information Mgt., FaPtGM+'1,:
1$1T M.A Mice Cantor- Raleigh, NC T7599.1617 Phone No, (919) T33•T015 .xt 565, Ra, llloo�a
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