HomeMy WebLinkAboutWELL-04-2015-059790.TIF ' tl 5.Alt;:4R S ,D,ENTIAL WELL CON T LUC .ION RECORD
1r� rI t of Environment and Natural Resources.Division or Water Qu81it}
.7� � ) North Carolina Department ...2210
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'^*.e. 0WELL CONTRACTOR CERTIk'1CAiIOi --
g. WATER ZONES(depth): r4-
t.WELL CONTRACTOR. 1 6 Qx,(/� Top—L�-7� --Bottom ��Q TOp OM
_
Well Convector(Individual)Name Top BottomTop BCtil"
,
' iii Top Bottom Top ,Bottom
Wet C. tractor Corn..ny Name Thtcknesa/ J
e° ._ /_I.i . . 1 4 7. CASING; t3apth diameter ' �//�
Street Ad rens Top O Bottom,/,Z t7 Ft, ,_4.____-"/ ..RS-C
/(� ASiza, /V( oZ g/6d( Top t�ettom Ft.
City o own Stale Zip Code Top Bottom Ft.
( AS)r) l 3- 2'5V)
Area code Phone number 8. GROUT: Depth Material Method
2.WELL(NI ORMA71gN: r Top /t� Bottom _Ft. l//YIh ( 71.447
..
WELL CONSTRUCTION PERMITS d'4 '04/�^d�7 ci 7 RQ Top Bottom FL
OTHER ASSOCIATED PERMIT:10f appucamo) (2Top Bottom Ft.
SITE WELL ID*(If applicable) iZZ,31 9, SCREEN:/f Depth Diameter Slot Stz9 ' Material
3.WELL USE(Check Applicable Box): Residential Water Supply® Top (./ Bottom Ft. in. in.
DATE DRILLED 2 /so Top Bottom Ft. In, in.
TIME COMPLk i tD 3 AM p PM Top Bottom Ft, In. m.
4.WELL LOCATION: a 10.SAND/GRAVEL.PACK:
C.Y�xn.Pirt ,COUNTY /1"3"b24/1,4,-;(_ Top
SizB Material
Tap Q Bottom Ft.
ra aQ ie'/ .Jg('/J Top Bottom Ft.
(Street Nemo.Nchoibers.Community,Suedtvtsion,Lot No.,Parcel,Zlp Code) Top Bottom Ft.
TOPOGRAPH'C/LAND SETTING: (check appropriate eoxl 11.DRILLING LOG
❑Slope I=Valley ❑Flat )tidge ❑Other Top Bottom Formation Description
LATITUDE __°_' "DMS OR 3x.xxxxxxxxx DD /
LONGITUDE "DMS oft 7x.XxXXXXXXX DD 1 1 JJ S f' "4,/.../, S c?�1 . IVIS
Lalltudeltongitudesource; CGPS (;jfopographlcmap / o�
(location of we//must bo shown on a USGS topo map andatteohed to / // FT 77, 3`7(< r-,'
this form tf not using GPS) I ,p
5.WELL OWNER / �.k .l0 1<.
•Yl tS/n h l
Owner N e 1
it ,`� Ziff f 1f l
Street Address d- /
% 4 .14.t.ar 1 .i
City or Town State Zip Code /
( ) /
Area code Phone number
12, REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH: gj 4• 1
b. DOES WELL REPLACE EXISTING WELL? YES[} NO I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: "6-0 FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(USe"+"If Above Top of Casing) STANDARDS.AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS / FT.Above Land Surface' •
//
'Top of oesing terminated et/or below land surface may require '� /_74 I/" 7 6 /O
a variance in accordance with 15A NCAC 2C.0118, §IG A uRE OF CERTIFIED WELLLAX/TRACTOR DATE
e. YIELD(gem): ,, .e METHOD OF TEST lt,<./[ �nA/�( /�i /
f. DISINFECTION:Type J� T Amount / r RENTED N1AME OF ERSON COi6 i R NGes" -e-//
WELL
ubm(flhe Vaginal td tthe
SSDIvi1istt lac t.Q ntyaotithim' iti 08'... -., ii ria lhm on Form GW-1a
1617 Malt Service Center=.RaIe)gh,NO,2 C'99.3t17 'k Phon ,Na • •
e '-(9S$)8ot311(, ` ,';,,-•.,-,' ; Rev.11/08