380164_Well Construction - GW1_20100107

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RESIDENTIAL WELL:CQNSTRUCTION RZ ORD
North Carolina Deportment of Environment and Natural Resources. Division of Winer Quality
WELL CONTRACTOR CERTIFICATION p 3007.-
1. WILL CONTRACTOR:
4.WELL OWNER
OWNER'S NAME ml Ica 1� frs
STREET ADDRESS
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STREET ADDRESS GAM MEtDuN
1— 001zOt
City or Town State
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2. WELL INFORMATION:
Site WELL ID opr eppleebee)
STATE WELL PERMITII(tapplicable)
OWQ a OTHER PERMIT OM uppicabie)
WELL ME (Check Applicable Box): Residential Water Supply (#
DATE DRn.LED : 00 11t42i6ar,oN ONI1f
TIME COMPLETED 1 -$-04 AM O PM 0'
i. WELL LOCATION:
CITY: DDRuG no COUNTY U ., ojJ
3 SK,EcRo f it)
• a
TOPOGRAPHIC / U1ND SETTING:
0S1cps.0VsSq BOW DRIdge pother
ON* somata* box)
LATITUDE _a.. L° 6
LONGITUDE,{ 0 °
LadtUdenoligipX10 some: elOPS °Topographic map
lEcdb mlettatntof bs Molvn on e USGS topo map end
ached to this room /not daft GPS)
Z$111.
Zip Code
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Ion. Lot No..
May be In degrees,
minutes, seconds or
ins decimal Ibmpt
MraTown Ne- ?8�9
C
State Zip Code
Area cads. rrlcrl9 number
e. WELL DETAILS:
a. TOTAL DEPTH: 00'
b. DOES WELL REPLACE EXISTING WELL? YES 0
NO sr
e. WATER LEVEL Bolos, Top of Casing: 30 FT.
(UN •+• 11 Above Top cf Casing)
d. TOP OF CASINO 16 1 FT. Above Lund Swine'
'Top d using Nmlinst�a below land surface may squire
a vaienos h accordance vNth 1 M NCAC 2C .0110.
L YIELD (=Prrrr...�� METHOD OF TEST AA
380164
V. DISINFECTION: Typo 70 °k *III Amount,
0. WATER ZONES (depth):
Fromss T FromTo,
From ' To FromTo,
From To From To
1. CASINO:
Thiciolseer
Depth Wais2From__�pp Ft!711ri Sh 1 From ToFt. _
FrainTo Ft.
T. OROUT: Depth Malarial
From O To 3 Ft. loR lAtims
Froin_'To Ft. Hrd
From
T F1.
O. SCREEN:
From
From
From�
Depth
To
_ To
_ To_
9. SAND►ORAVEL PACK:
Depth
From TO
Front To
From To
10. DRILLING LOG
From To
0 21
2I 70o
11. REMARKS:
Mgrld
Diameter Sla Size MOM
Ft. In. h.
F1. In. h.
Ft. In. h.
Stze Maleder
Ft
Ft.
Ft.
Forrnetlon a.rDesalptbn
kitaido D►ar aoco
E SLAW lr711
e i I esi!1./tl�r
72010
WATEr QUALITY SECT:r ,
` •' rlucessslilg Unit
I DO WHY CORTVY TNAT MS Wall WAS COMM/CROW ACOMONCI YAM
16A RCM ?C. WILL CONSTRUCTOR STANDARDS. NOW ADOPT OF MS
RECORD 103 SEEN PROVIDED TO THE WELL OWNER.
G ATURO E F E TIF1ED WELL CONTRACTOR/2 DATES
PA PAL L. OpLmtvg.
PRINTED NAME OF PERSON CONSTRUCTS THE WELL
Submit the original to the Division of Water Quality within 30 days, Attn: Infomtation Mgt.,
1617 Mall Sams Center— Raleigh, NC 27699.1617 Phone No. (919) T33.7015 ext 565.
h
For G141t1,e . .
Rev. 7109