HomeMy WebLinkAboutWELL-11-10-12930.TIF 03/02/2011 21:37 7048924705 B K WELL DRILLING PAGE 01
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. R'�IDL7vrzAL WE4i CONSTRUCTION RECORD �i /
3 / North Carolina Department of Environment and Natural Resources Division of Water Quality
:=• WELL CONTRACTOR CERTIFICATION # 3265 -A
1. WELL ONTRACTOR: g. W ER ZONES (dap
RaIoh ailev Top ,� Bottom !! Top Bottom
`
Well C ntrector (Individual) Name Top Bottom I { ) Top Bottom
•.B -••• • 4 = Drilling Inc, Top_, Bottom. Top Bottom
Well Cio tractor Company Name
132 M Thickness/
me Lp 7. CASING: Depth Dlamatsr Wolght Material
Street )Andreae
Top L/ Bottom ,c? Ft. 8 1/8 SDR - 1 PVC
City or Town lop Bottom FL_
State Zip Code Top Bottom Ft,
C 704 i 02-4696 Arse coo ) Phone number 8. GROUT, Depth Matenai Method
2. WELL ( HFORMATION: Top 0 Bottom 20 Ft. Hole Plug Pour /Hydrate
WELL CONSTRUCTION PERMITt3 �� '� / 12 — Top Bottom FL
OTHER ASSOCIATED PERMITIN(If uppllrible) Top Bottom _ FL
SITE WELL ID *cif applicable)
0. SCREEN: Depth Diameter Slot size Material
3. WELL i/SE (Cheat ptIce e@ox)' Restdeneel Witter Supply p/` TOD Bottom Ft I In
DATE DRILLEDS7 ` / Top_ Bottom Ft in. In,
TIME MPLETED C. t1 PM [/;../.-- Top Bottom Ft. in �~
4. WELL 10. SAN VEL PACK:
CITY: (g L� "T 'L.. COUNTY �/T Z �e4 S Material
y
l Z f / - Top, Bottom
374.4 -'- }- Saria1r Top Bottom Jr FI _ "`
(Street Arne, Numteni, Community, Subdiv)umon, Lot Np, portal p T Bottom Ft. � `' —
� � .
TOPO PHIC /LAND SETTING: (chetic appropriate ) OA / r
pit El Valley a Flat q Ridge r) Other 11. DRILLING LOG
LATIT E 36 •• T m rtna ' Daacnption
"DMS OR 3x,XXXXXXXxX DD C--- / L 4 eej5 C 2 A y
LONGItUDF. 75 6 Gz^ _[.c- 0
I "DMS OR T X.xxxxxxxxX DD W ) et/ .��
latttude>14ngltudesource' PS 2��_ � � 'c' /l� [�G []1 opogrephfc map (location of wet) must be shown on a USGS topo mop andottached to /
this lorrtl of not using GPS) /
6. wiu. OWNER /
f 4 N'1 f c44e / A -z e. $ /
Owner 1,Jitme /
��i�� /
Street Levees /
Atl
City or own State Zip Code /
( — /
Area code Phone number
12. REMARKS:
0. WELL DETAILS: .r7 - -
a. TOTAL DEPTH: L
b. DOES WELL REPLACE EXISTING WELL? YES rJ NO 13.
(�O I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
C. WAI LEVEL Below Top of Caning: _ ,7 FT. ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
(Use �` a Above Top Of Cening) STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
if / PROVIDED TO THE WELL OWNER.
d. TOP OF CAS1NCi IS ( FT. Above land Surface' ,t / �! s
'Top Of casing terminated aVOr below land surface may require ac �Z'` ` (. r iL / /
al variance In accordance with 15A NCAC 2C .0t, 8/1L„,_ SIGNATURE OF CERTIFIED WELL CO CTOR 0 T E
e• YIELD I (goal. 2 / METHOD OF TEST O/ o /,-- e //9 1. 4. / /eV
f. btt31N C.-
FECT1ON: Type 2 /. Jam _ Amount / L PRINTED NAME OF PERSON CON�TRUCTI THE WELL
S 1 iii iii l Tin 3 Ca r p ; 00 NC X7699 3 .c4.W9 t # . elf0 Form GW -ta
Rev. 2/09