389292_Well Construction - GW1_20101206

1. WILL CONTRACTOR:
RANWLy�.Ouvett
Rid Contractor (Yrdfr outi) None
CARD
=Motor Oanperry Nuns
STREET ADDRESS Lcia MetD'u'+ f .
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ci T--erg . Ip C
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L wSLL INFORMATION;
WWII WELL ID OR acacia.)
RATE WILL PERMITIPRoppace a)
QWQ or OTHER PERMIT R(M epppo.pte)
io - 112
VALLI sl (Chet( Appaoebte enot): Rao IOorttlei Water Supply 0
PAT' OR LLEo 10 -1I - to i 6k-rih'' pout
TINE COMPLETED c/ i oo AM O PM
S. WILL LOCATION:
CRY: .Rro)tt}ra COVNTY UPto,3
5C0a OsiD4Es E66E mR(WIH c. peoe_ L45`425z
rIMtme. Mik* Wont,* kibtLislon, LoiNo„ Pan:0 Z1P was)
TOPOOMM(ICItAND SETTING:
Olio*. OVd.t 50111 0 Ridge 0 Other
Mad mead* boa)
LATnwi ..L ,5` of) , 303 Al
LONOITUOSL
Ms): be In &pose,
minutes` ma* a
In • dealms, P rrrut
�,�_ooum,: BOPS OTopographicmq)
i • • t o�rtaiwelmattbta shown on • V30S hope map •nd
dianadbhitIbrm'not who OPS)
4WILL OwNq
OWN:IMAM' SrEve 21e,.j EeK
$TREST ADDRESS _ 5001- C Roves
W�ic rWw pc- 2 t'?3
Wa oltn t•te Z
243-4%1
Vood� Pima number 4
'WILL OSTAILOr
M 'TOTAL
00114 1SLLIMPU ; lfiOTINO WBLL7 Yea 0 NO C+/'
"ATER LAME awowTop of Ca•1ng: Fr,
pew MA*, Top d Cooing
TtIP CF CAPIN_ p I FT, Above Laid t;I:ri oo'
`Top of S MRn ow hnd 'Woo Miry roam
• rlrlarloa h aooa mod t t 16A NCAC 2C , 011$,
YD(91mk_ /8 MMTHOO OF TUT
RESIDENTIALWELL CONSTRU LION RECORD
Nottlr Caroline Deportment of Environment and Newry! Resource*. DIvIiIOf of Wets? Quality
WELL. CONTRACTOR CERTIFICATION N 30o2 A
r, DISINFECTION: Type -70ei Of"
•, WATER ZONE (depth):
From 9 S To
FranNv`7 •,To,
From (/ S. To
I, CASINO:
From D OToth 85
From To
From To
a, a1)6,1/I L
." tiU 4" .3 ,d
Amount o z .
From 215 To,
From .3 IS. T
From,
lemetor
Ft. Oho r
Ft.
Ft.
T.OROVT: Depth
Fran 0 To 3 Ft.
From 3 • To 20•r Ft.
Fran To Ft.
1, SCREEN: Depth aan»ter Skit 040
Fran To Fl. In. P.
From To Ft. In. h,
From To Ft.
_. To...�•!�
Theo ooety
Soar 2: vc
t, SANWORAVEI PACK:
Depth SW Molorlr
Fran To Ft..�_.......
From ,_•�To_- - Ft. ,
FromToFt.
10, DRILUNO LOG
From To
5
5 3o
jo
58 7S
'7 5 'i55
11, REMARKS:
MOM
opt
WPM
Formation t)••aIptb1
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Dlru
ANA
ae..4.) . ' i •7E
�t�on Prod
Inform• �\NQIBGG
I CO MUM CS1TR[ RT►T TINT MO WELL WAS 0000100011gi N AOOOIOIIg 1ti11I1
1IA MGAO:Cc, Wf L , OONST1l..CT10N •TANOAROS, NO TINT A OOFY OF nIt
IIICORD IV►t HIM FRCVptD To TMI Wall amain.
►^KA,�KiF L.Ouvetz-
RINT€D NAME OF PElt$ON 00
Submit% *NM to the Dh ision of Water Quellty within 30 day., Attn: hfortnation Mgt,
1.11 MIA Seta Center- Raleigh, NC 275994617 Phone No, (919) T334015 ext 500,
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Fa(n rilyld,E .
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