380571_Well Construction - GW1_20100129

RPSIDENTIAL wzussearnucrioN RECORD
North Carolina f 1 Department of Environment and News! Resources. Division of Water Qualhy i
WELL CONTRACTOR CERTIFICATION N 3007-
1. WILL CONTRACTOR:
(.114%-lE L,.OuueR..
Wa Contractor (Indtwidull1) Name
ems
STREET ADDRESS (obit} (flett4 , .
�ou e� tJC 2.8$I2..
r•"r or T Own toe Zip Code
�M f70de• �
2. WELL INFORMATION:
SITE WELL ID IRS woosaMe)
STATE WELL PERMITS(vepppo)
DWQ a OTHER PERMIT FM eppecatb ,) D - 201
WILL MI (Chsclt Applicable Box): Reeldenttel Witter Supply I9(
DATE ORILLI_ I %- I0
TMtn comeu TEt7_5 :0a AM 0 PM (g'
3. WILL LOCATION:
CRY: WRx NAu1
?L23 (,t,) enenc.
TOPOGRAPHIC/ LAND SETTING:
OeI pit. C t W mow 00ther
LAT1UDE t �° 5o. /47o
LONGITUDE 8 0° s.g
[a tituk/l she: tai3P3 DTopographIc map
lbc+ ►•ofwe/Mit* a1►oln, on a USGS tope map and
Nbohodlohilt Awn /not grip OPS)
4 WELL OWNS
OWNER'S NAME
eft
STREETADDRESS —522 3 G oo.. C z Re
HA+J
Msy tat In Negress,
minutes.. cads or
In a decimal Ibncer
Zip Code
1. WELL DETAILS:
TOTAL DRAM 35o'
a DOES WELL RERACE EXISTINo w5LLT YES 0
a WATER LEVEL Below Top of Comm 30
(Ulf NAbor1 Top d Casing)
d•. TOP OF CASING: p FT. Above Land Dorton'
Top Red dice beim low admit may 'WW1
evive h maxima Wth 15A NCAC ZC .011 e.
p` YILD (W m):,....S.,,,,,,. MVTHOD OF TEST As,
3
NO te
FT.
f, DISINFECTION: Trp», 9% tnnj__, Amount 2Vf o2.
e. WATER ZONES (depth):
Fram 0 To From To
From " ToFrom
From To From
I. CASINO:
Fran 0Depth
To /0,5
From To
from To
Ft.
Ft.
Ft.
7.OROUT: . Depth
From..�0 To 3 Ft.
from ; To 354' Ft.
From To Ft.
E. SCREEN: Depth
From To
From To
From To
e. SAND/GRAVEL PACK:
Depth
From To
From To•_
From To
19. DRIU INN LOG
From To
D o
�O 25
43 35fl
11. REMARKS:
To,��
To
Thlacreaa/
Z 5i M a
,�laler{p
t/ Q,T atm.,
Diameter Slot Stu Me>lern,
Ft. In. In,
Ft. In. h,
Ft. In. h.
Ft.
Ft.
Ft
Slue /Mari
F • rmstbn Descr ption
6
'. AND
GaAmsTE
stow .,:,e.M•a
1�1y9,V/111I1
INN Lr Y SEC 1"ION
Interrr.•-:ion Processing Unit
D0 PUIIY CSRTFV THAT De WEIR WAS CONPIRUC1W NA000RDAICE NTIN
ISA NCAC IC. WILL CON$T1WCT10N STANDARDS. ANDENT ACOFYOFDell
RECORD NAS NEIN FROVVED TO THE WELL OWNER.
4,1 I - IL- Ia
rtR OP E , WELL CONTRACTOis
tW1�KrE L. UI,IVet
PRINTED NAME OF PERSON CONSTRUCTS THEAVEU.
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1111711,0 ire tIIce Center. Raleigh, KC 275e9.11111 Phone No. [phone] ext 555.
1
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