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�ole+liasteter. /� Division of Water Remureeer Infoneafloo Preemies UR%
11.80 161T Mail Service Center,Re►elgb.NC27699-1617
12.Well � ?Ab.Thar Late iiea ttYelt.• to addition to
Ito.taiga:, 1 �Q nitifltodh ---t = 24b. .elan subs one sending the form to the addtteai in 2An copy of this form within 30 days al complexion of well
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cnnstmidion to the foNmPinX
FOR WATER s-1:7.7--1 t- ONLY: Division of►Vatq•8
eacereese u36 Wail Service Censer,rground ilrUeittoa Control progmtge
13a.Yield km ,1lttle(gli.NC 2701 t636
Magma of te3C 2 c. ytrQter Rottttaiv&tahl_ae.>+ a:tab.Disinfection�+�;, the eddrCs.S(CS) �addition m sanding Ills farm(t1
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tvltlela congtroete� It>?alth dCpmvr.cQl of the county
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I hereby catify its the above referenced well was groom in appearance In accordance with
all County Well rules.
well Driller. Cl ex Mead ho s Signed: -
Cerrftcate#: 2 t t 3 -A- _ Dew Groub3d -,„2-_.>._
Construction: Grout
Total Depth; Type;- L� �-�
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Casing
Sic� Thickness: M 1.,(4€
Casing
: h: LP ..
Diameter:
Drive shoe:
GPM: 30