385298_Well Construction - GW1_20100719

1. WILL OQNTRAOTOMh
FRANKt l_ Ott
a aryl
TT '..MA WE
FRUIT ADDRESS — MeteLiP4 Rp,
1ONRp
70Y tyor Con tato YIP CiOW
.� $O
L WELLINFORMATION: .
SITE wE L ro /i. eppo0a01e)
KATE WELL PERMIT ',atonal.)
DWQ a OTHER PERMIT PM oPPrio+e+.)
WELL USi (Chock App'tablo Ste: Rooaerttitttl Water Supply l7
DATE ORtLISD_ -/o— /o //IA 6 Aria.) ONi.4
TIME COMPLSTID — pAM to PM at
i. WILL LOCATIOfft
O11Yt 10Aic / Mw
GOVNTY tla✓aora
5taq (A)►w
isr4�"' . 1-1.J. IA144.401 M. L00#3
TOPOGRAPHIC/1AM $ETTiNG:
CNope.OV.ky EfFlot ORIAp. OOther
(*WI ttppgrkis bag
immure _T... 5 ° Oo4�
LONOITODE $ O ° ALlitezL
�f : IP3 t7Topop*ph(c map
dlo m I oiown an a Usys tared
d wI ptl R Grp OPS)
tINMI u dvFp
STREIT ADDRESS
�t�+ac• t1A�v
vor awl
_7°` 1�7-4Zpo
$ WERE, IUTAIL$I
TOTAL DIFT#It 4051
b, DM WILL REPLAN EX/IMNO WELLT Yee p
E• WATER LML IWorrTop d Cowing: 25
Pee ',Above Top d Cooing�j'""—
d. TOP OFCAM p /
to —SI
FT. AtcY9 Lino wpm'
linnTaar—E;rou *or
ov rlent:9he°°admo 15 NC oCe2C,p11rnw
�
d YI LDWog: 25 MIITHOD OF TEST AR-
NG 28113
tate Zip Co e
May be In deems,
minutes, woad, Of
In dwirnsl Wm:
No Gil
FT.
�q� ia,�ir�C.
RESIDENTIAL WELL CONSTRUCTION RECORD
Notth Carolina Deportment of Environment end Natural Resources. Division or Water Quality
WELL CONTRACTOR CERTIFICATION N 3cozA
f, DISINFECTION: Typo
S. WATER ZONIS (d,pWN):
Fran.....AM To
From ' To
From To_��
e. CASINO;
"70
From 0Depth
To 73 Ft.
Fran To Ft.
From To Ft..
T. OROVT: Depth
Fran0 To .3
Fern _. To �.t
Fran To
e. SCREEN: Depth
From To
From To
From To
P. SAND(pRAVEI PACK:
Depth
Fro''n,, To.
From To
Fran— To
10, DRILLING LOG
From To
0 3
II. REMARKS:
From To
Fran,
Fran To_-
Th101bnety
Olsrneter Wsipftl
log/R" , SOR21 VC
To
MtttorlM
Ft. Par1ivat.
Ft. &,..iu-v rrE
Ft.
NMftoO
84.412.
01.nmter eat She Maw
F1. In. h,
F1. In. h,
Ft. in. h.
Ft.
Ft
Ft
Sin Maoris)
Ft:motion
o
�w jiiEii" G
QRau„a SA0-njaa41.
GRA�,rE.
"r \ /IC I
Nam, tie v t�
JUL 1 9 aiti'
formation Processing Unit
DWQl8UG
100 HUMP Ctl1Tp . TWIT MS WRt1 WAS 0ONSINUCTIDNAA000IEANNWSW
t$A NCAC tc. WILL OON$TALKMON STANOAROS. AN0 TINT A COPY 0p HIM
RICCRD Kg KIN ►R0'47,0 Tv TM WILL wax
>�Raa�wE L. Ouvt:l
ORiNTED NAME OF PERSON COMMIRTEVIEti
1ibmit the original to
11 Ms Division of Water Quality within 30 days, Attn: Information Mgt,
RdeIgh► NC 27399-1011 Phone No, (919) 7334015 'xi 568,
Ftxpi• 0�►11p
RN.1A6