386095_Well Construction - GW1_20100809

RESIDENTIAL WELL- CONSTRUCTION RECORD
Noah Cnro1ina Dcpartmant of Environment inq Natural R.e9otrrozs-Divi3ion orWiirvr Qualify
WELL. CONTRA.CTQR CERTIFICA.TIO N.11
AhiPi Xlcs
3.8t095
�. \YELL �QNTRACTOR:
v- /5 ,, /f n c/,' )
Yvcfl Cooly- far {Inoiviau" 1) N
vv cu Conu__tor Camp -any Narna
�T icET ADDRESS oU / , i
ZS-o 9 2
Ca) of Town Srds Zip Cope
7 ch 1 1- 5'5-- 2- 4-/ / 3
�raa c as Pn0114 nvmr;sr
?. WE- LL INF,DRal.ATION:
. SITE WELL ID "kid>ppliCSm4) / d CG 3
ET.=,TE WELL PER rMT4tu.ppric3Dr:.1
0w or OThER PERMIT r(ir applicable)
WELL u_E (Cpnr ,pplicaDlc dax): Rawamtial W-iicr Supply
Q ,TE DRILLED_ 2 3— Z C%
AM — M ❑
TIME CQ2AFLETED / e) 'J cU
3. WELL LOCATION:
CITY: I
COUNTY L1/ /I / t* h
1 tt.4t N ma, Numo.r:, Comm411/y, Su4nrvtsron, LP( NO., Parcel, 2ip Co4e1
TOPOGRAPIile r LANR SETTING:
Ll$Wpc ❑V:ii y ['3'Ptf ORidg4 OOlhcr
(cn4cr: iapropnak boz)
L;TITuDE
LONGITUDE
May to in dcgress,
minutes, sccotuis or
in a cl cirnal format
j tirudc!lomgitude sourea: 1> S gTopographic map
(localsan of t must Oa snorrn on f.U3GS rapo map and
anacnaa fa rn;s farm iYna using GPS)
WELL OWNER
OWNER'S NAME
STREET ADDRESS L-1 2- L)44/
fir �
//-e )i i. _ r .. `•
City or Toi,n
�raa Cvgo . Poona numou
*. WELL DETAILS:
�- TOT.r,L DEPTH:-. / �d.
DOES WELL REPLACE. EXISTING WELL? YES Q NO
�tala Zip Code
Q. IYATER LEVEL 6*Jo,v.Top of Casing:
(U3v'T I( Above Top or Casing)
a. TOP OF CASINU IS / t-
1'r. Above lgt1Q Suf1aC2'
'Top of essirQ terminikty,1 it/or bgow Iano surface may require
y+ri;rlGc in accorcianc; with 1 oA NCAC 2C .0114.
YIELD IBpml: mETttOD OFTE$T II T 171—
f. OISINFECTION:-Type q; ijfJtwJ'f' Amouni
g. WATER zONES (4pt11):
Front S.—To
From
From
6. CASING:
To
To
From From
From
�) f Depth t Diarutiter
From±/ To 3 &' /7,FI. 4 r`,(
From To Fi.
From To Ft.
�J C KtO,)
To
To
To
Thickness/
Weigh!
SJZR 2(
M ai onal
c
T. GROUT: twin Material
rr _ Melhocl
From 0 To 35— Ft. f ,7 I( 7. ?? J i- .-V m
From 'To Ft. /
From To • FL
9, SCREEN: Depth Diameter Slot Size
From To F(. ih. In
From To Ft, in. in.
From To Ft, • in. in.
9. SAND/GRAVEL PACK:
Depth
From To
F.
From To F.
S'Iza
Material
Material
From- T9 F.
10, DRILLING LOG
From To
/-•
3 b-.'/g_—cfVG
11. REMARKS:
Formalion Rescriptian
74, //7y
I K
RECEIVED
.4Ub — 9 2010
Inror _
100 ryEREBY CERTIFY THAT7N1$ WELL WAS COI- TRVCT4Pn :1
15A NCAC:C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF 1111�9 '_
RECORD ItAS BEEN PROVIPEDTQ THE WeL, OWNER. .
E ER7I
CONTRACTOR
NATURE OF FIED WELL
PRINTED NAME OF PEF(SON CONSTRUCTINOTHE WELL
ANTE
SuQmit tns original (0 the QIVISi411 of Water Quality within 30 clays. Alin: Information Mgt.,
1617 Maa aQrYiCv' Ccn(fr.. Ral+iigh NC ;7654-1417 Phone No. (919) 733.701xi 664.
Form GW.14
Rov, 7105