HomeMy WebLinkAboutWELL-07-2015-063314.TIF 08/25/2016 07: 00 FAX 2
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ww RESIDENTIAL WELL coN TRLICzION RECORD
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'Mp�r, ,�/ North Carolina Department of Environment and Natural Resources Division of Water Quality
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~�"="fs WELL CONTRACTOR CERTIFICATION H a42 3.5.
1,WELL CONTRACTOR; Jn" � // g, WATER ZONES(depth): /t
J(L►••'✓ei�9tKU 4..11 Top /d &horn 4-24o Top Batton
Wall Contractors ridivkluel)Name Top
Top Bottom Top Bottom
//.CIA�C,(L(.L(iAI/L'Gf' Top Bottom Top Bottom
Wall Con�}or Company`/ Na/me Thttaneesl
;LTV, ddan A 'eel 7. CASING; Depth Diameter Weigh Materiel
Street;7;a48 '/ �1 y� d/ Tdp TO Botom //.,� Ft. GZa _S ,2/ ET ') � ia�n 1 TOP Bottom FL 4City or State Yip Code Top Bolcom Ft.
( g , honsz 0371
Area coda Phone number
T. GROUT: Depth Material mod
2.WELL INFOAhtA11ON: Top l' Botlam�2O Ft. ,44141/7421,.., '!n �
�
WELL CONSTRUCTION PERMIT* Top Bottom Ft.
OTHER ASSOCIATED PERMITS/�SiI♦Iqff appellee) 4 lop _Bottom Ft. rl -- !. 64;415-
SITE WELL ID#0 appllmtxe) Z&3a O. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Cheek Applloeble Box): Residential Witter Supply® Top 0 Bottom Ft in. in.
DATE DRILLED Y 21 /4 Top Bottom Ft in. In.
Top Bottom Ft. In. ,._. m,
TIME COMPUTED '1/ AM El Pp.1e
4.WELL LOCATION: 10.SANDIGRAVEL PACK:
I /` Depth Size Material
CITY: ,V/LLCOUNTY_ Qa d.� Top 1) Bottom Ft,
T.QL •G1t LA omp toryAM 2 h'/6 5••� Top Bottom Fl.
(direr NAM.,Numbers. ,SutdNNbn Lot No..Penal,21p Caw) TOP Bottom FL
TOPOGRAPHIC I LAND SETTING: (area eppropnme boil T9,DRILLING LOO
lope Ti Valley D Fist 0 Ridge pother Top Batton ForrnatOn Desattetlon
LAT RID! . '_' "DMS OR 3x.xxXXNXXX)c DD /
LONGITUDE'_' ' "DMS OR Tx,)000xxxxxli DD 70 / /O.< c S
Liteudenongltude source. QPS propoproPhio map / 14 6--
�><' ,..� �O�v`�-�
(location of well must ho shown on a usGS topo map andptte ,ea to /
this(este if not udng GPSJ
O.WELL OWNER / gir..lantst0 ./ -
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Owner Name �..41 f/ / p� /
Street Address d 1
City or Town State Yip Code
( U2 367/S'6/_ l
Area code Phone norther 12, REMARKS:
8.WEU.DETAILS:
a, TOTAL DEPTH: ELC9 FT
b. DOES WELL REPLACE EXISTING WELL? YES 0 Nigi,) I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
e. WATER LEVEL Below Top of Casing: .6-0 FF. ACCORDANCE IMTH 1 BA NCAC 2C,WELL CONSTRUCTION
(Use-+-If Above Top of Castnp) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THF WELL OWNER. •
d. TOT OF CASING 19 FT.Above aS requ7YJfQ� 4/fJ //_
`Top of casingt: In terminated wtth below land 2C.0surface may require r a
a variance In entordanos Willi 15A NCAC 2C.Ot 18, SIONA URE OF CERTIFI LL CONTRACTOR ATE
e, MELD(WS.rkO _METHOD of TtST� A I, 1', . s .4 a ' .rrv. -.m
I. DISINFECTION:Type Airel Aoum -- N D NAME OF PE' .7e1 . •N• -u E r.A
Subtnff4ho ongltral'tbttMn UWlsiotf ofW Ql*YdlltyaiitSin Sidayex A6 rt11'brnratbo 1i..t-, 4' Form GW-la
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