385297_Well Construction - GW1_20100719

RESIDENTIAL WEL1..DINETRUCTJON RECORD
Notth Carolina Department of Environment and Newel Resources- Division of Weser Qualhy
WELL CONTRACTOR CERTTFICATIO
1. WRs.corrRACTCR:
Rod Con aute L_ °L.iva..
r ( du41) Name
a�ROU.vA IJi✓r.c.. 2rr.4.
Wei Coiwacta Oanpary Meru.
t3TJ1EET ADORt:e5 14I4 inetxi.., P .
E 24112
City oTown --gtate C
7oq 7101.' 05.
^"a �►1� num or
L WELL IM'OIwAT1ON: •
llTtt WELL ID e Tsppam*
ETAT, WELL PERMMItt twwtett4t)
DWQ w OTHER mum PO ) /0 -61
MUM (Chock AP ANN, Boxy Roo Idyllist Water Supply®'
DATE DICLLtp I a
TMIt COMM.tno too
i. watt. LOCATIOfh
art — mor+QKr COUNTY
s ,
O11C t LAND 1ETTIN0:
OVIII71 Whit WWI0R idgeO other
�Rwilele
LATITW,E.,i° 5 .53i /+
LONOITUDE $ O° 30
.,
LaIltudellonskodonu°'0I: ®'OPS O Topographic mep
i' ►ofaNnxist shown o+) s (SOS tops map and
*OW brit Ibnn/rpt why GPS)
4 MIL OWNER
AMO PM®'
May be In daaws,
minutea.aeoond, a
ins doelmei brim:
OWNIR'0 NMISTREIT �NI
ADDRESS
or Clln .. Nt Z$'iIZ
tato Zip
�,,.�� (03K- 19
MiO. arMn w
VIBE DETAILS
IL TOTAL DEPTII00'
th DoesrrnLRnuot warm WELL? YE, o NOB'
I. WATER LM . allow Top 01 Cestng• 3 g' FT.
pew May Top d Casinp
d. TOP OF CAM M I FT. Mgt, Lend Moot'
'Top d sail M"^ ietend what entry requite
IIWil 0eh Ictadd100 with 15A NCAC 2C .0110.
, Mtn (9Pmk--IL METHOD OF TUT AR
IVN
.3cnzA
N41 laI A/CA c
s5297
f, DI$tWPtCTION: Type
e. WATIR ZONta (depth);
From 570 To 'From To
From ' To From
From To From,
O. CASINO:
To
Q Thickness/
DepthFromFrornTo I4q , Ft. LO 8" W r ~
To Ft,
From
To Ft.
7, OROVT; Depth Maeda
Fran 0 To 3 „ Ft. PoCu O
From 3 To 36* Ft. C36 JTo, tlE•
Fran+ To Ft.
e. SCREEN:
From
From
From
Depth
To_
To
_ To_
Otemetyr eta e4e
Ft. In. h,
Ft. In. h.
Ft. In. h,
MegrW
V. SANWORIWEL PACK:
Depth Sits McNry
Fran To Ft.
From To Ft.__
Fran To Ft.
10. DRIU.INp 1OO
From To
0 /8
it &op
11. REMARKS:
Form tlon D.ecripfbn
QI¢owr Did2r/Itocre-
ormation pr anc; sing Unit
�`1 G
Do P MIT CERTIFY TWIT no Wet.( WAS CONITIN)OtID II OXMAN IUfW
I1A NCO c, WILL CON$TRIJC ON $TMIOAROS, NOTINTACOP( CF1111
',CORD Kg NIN ►ROWOtD TO THE WELL OWWIR
7-8-10
'
CERTIFIED WEu 6it CONfRACT
r+K 1E L - OL►vtCL
ORINTED NAME OF PERSON C--C U iNG TFIEWEU
8 the ��d to the Division of Water Quality within 30 days. Attn: Information Mgt., .8161111..
.11 Myi'F
Cantor.. Raleigh, NC 2799E-1017 Phone No. (919) T33.T015 Irxt 555, 01�►��s
`' Rot 7A6