387612_Well Construction - GW1_20100107

1. WELL CONTRACTOR:
i✓VeE Contractorf-If
W�E_
(fndhAduW) Name
C 124t4^.R 10 Er., iDz,nr-r G
Well Contractor Comp.ny Name
STREET ADDRESS blot q Abut/ a.
inoiugaeNi-
City or Town State
t N }_i7b 4f �oS K
0000ddeehate number
_. WELL INFORMATION:
SITE WELL ID /(Mepplicepi)
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of -Environment and Natural Resources- Division of Water Quslhy
WELL CONTRACTOR CERTIFICATION M 31aO2
2$/12-
Zip Code
STATE WELL PERMITR(repplleapte)
OWQ or OTHER PERMIT t9(I► apPticabie) C79-1,12
WELL USE (Check Applieapy Box): Residential Water Supply (if
DATE CHILLED /2.-
TWE COMPLETED 9 : AM 0 PM [•+l'
3. WELL LOCATION:
CRY: orrpoE
TOPOGRAPHIC / LAND SETTING:
081coe OVeMy fifFNt ORidpe to Other
(shalt eppropta4 boa)
LATITUDE
LONoRUpE 8Lititudenongi
tulle Koran BOPS OTopographic map
• (cs5aP.rlselmust be shows) on s VSGS typo map and
1B+cMd fo * form /not using GPS)
4 WEU. OWNER
OWNER'S NAME.�l�(�.�u� e Es a+c
BEET ADDRESS -fig
-
NG
Clio aim ' ' State
mSfol
0.WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES p NO to
O. WATER LIVE BNow Top d Casing: 35 FT.
NH's, I Above Top of Casing)
d,: TOP OP CASING 1S FT. Above Land Mew'TOP d casing IumYI war bMow land swine May require
e %advice In ewe v.Ith 15A NCAC 2C .0110.
IN YIELD (9Pm1. 20 METHOD OF TEST /ha
COUNTY UNi+
Ion. Lot
Mar be in degrees,
minutes, seconds or
in a docimel format
„17
Zip Code
/1/4Ai Pi OP C.
380164.
T. DISINFECTION: Type -10 °T-14rr Amount o2 •
U. WATER ZONES (depth):
From Ill T From 2. To
From 392- 'To_____ From To��
From...ALL ToFromTo S. CASINO: T w
Depth Odometer WeightPA From ,Q _ To c7/ Ft. to " Sb 2 •Z..1 VG
From To Ft.
From To Ft.
7. GROW: Depth ,[rletatal
From 0 To 3 Ft. j_ 1�F_
Frain 3 .To 3S4-Ft. EN .r
From�w To Ft.
S. SCREEN: Depth
From To
From
From
WSW
Demeter Slot Stop Mil uIW
Ft. In. In.
To Ft. In. In.
To Ft. In. In.
9. SAND/GRAVEL PACK:
Depth Size Materiel
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
0 Bo
*Co
11. REMARKS:
Forrnetlon Desortptbn
Uawr 1 Z.r� /Rorer
L..6 6.1.emir
Al 0 q
zup
,ocessing Ur
1001#REST CQRTtt'Y THAT Ties Wall WAS CONSTRUCTED N ACCORDPNCI MwTM
I IA NCAC IC. WILL CONSTRUCTION STANDARDS. ARO THAT A COPY OF INS
RECORD IMS SEEN PROVIDED TO TWE WELL OWNER
CaZL sad 12 -.11-d1
E OF CERTIFIED WELL cfflinTatDATE
ti�INIZtE L. OLav
PRINTED NAME OF (PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days, Attn: Informetlon Mgt.,
1617 Mail Service Center- Raleigh, KC 27699-1617 Phone No. (919) 7334015 eat 565,
it