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COPJT I FdIJE FROh1 PRE'J I OIJS PAr,E �� i
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J{�- _ . D, �ESIDENTIA,L �L'EC.L CUNSTRUCTION R�CORD
�� �` ' 1 �" North C�rol�na DepaRment of En�•ironment and Natural Resourcc;- Di��i�wn ef Watcr Qualiry
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• � a �� ��'�I,L CONTRAC70R CERTIFICATIOh # 2 S H 5
1. WELL CONTRACTOR' f. DISINFECTION: Type Amount �
A s h 1 e y T_ M o r e t 2 g. WATER ZONES (depth)
Wetl Centractor (Indivlaual) Name From � � To �z s From To
M O 1" � t Z,� P 1 L 1^ i 1 1 in T From�_ To yoS From To
Well Contractor Company �Jame From Te From Tu
STREET .4DDRESS 615 9 H W Y. 10 w P_ S t 6. CASiNG Thicknessi
Depth D� �rr� � e � r W h N�at I
N 1 C k O 1^ y N C 2 8 6 0 2 Fmm�_ To��Ft. �/JK- .2/�C.
Ciry or Town State Zip Code Frem Tc; Ft.
( 7p4 �- 4��— � 322 From Tc Ft.
Area code� Phone nurt�ber
2. WEIL INFORMATION' 7. GROU7: Depth Materlal Methnd
��/�� /��_e�_�� From�_To�Ft,�__� 0!�
SITE W ELL lD #(if �opl�cshle) �V ,�� Ov from To Ft.
STATE WE�L PERMITk(Irappucatie) Frc�m To Ft.
�WQ or O7FiER PERMIT K(if aopficable) E. SCREEN: Depth Oiameter Slot Size Material
WELL USE (Check Applicable Boz) Residentisl Wster Supp�y � From Ft. in, in,
r � ��� j From To Ft. in, 1
OkTE ORILLED Fro - To m. In.
T►ME COMPLE7ED �� 11M p FM �
9. SANDlGRAVEL PACK:
3. WELL LOCATION: Depth Size D,laterial
CI7Y: COUNTY�,-�� From 0 Fl.
/' Fror� To
Inl7 3 Gr�,i ��� Fro 7o Ft.
(SVret Name, um r, Cammun�t�, Su ivision, �ot N Parcei, 21D Gode)
TOPOGF'.APHIC t LANO SE771NG: 10. ORILLING LOG
OSiope �alley p,Flat ❑Ridge pOther �m o � • Fo atie Descriptien
fchack aaoroan t� borJ �' � r`�
S �� �/ 1�fay he in degreei,
LATITUDE 3 m�nut��, sccc»ids �r � i Q �
LONGITUDE $ �� 3. / �� � 'n a dccimal form9t (,�_
Latituddlongitudr sourcc: PS p1'opographic m�p
(location of well musf be shown on a USGS topo msp snd �
att3ched �o this lorm if ne1 usiny 6PS)
@. WEtL OWP�ER M1
OWNER'SNAP�AE ! �u�� �I n��^ �
57R�Ef A DRESS � M/
�; c- a �'s/ �/� 2 R� �
Ciry or T�o�m State Ip Cod� e —
( ?-
Area code • P�one number
11. RENIARKS:
S. WELL DETAILS: �
a. TOTAL OEPTH:
b. DOES WELLREPI.ACE EXISTING WELL� YES�NO p
I DO �fEREBY CERrFY T1fAT THI� WELL'JJA� CONSYRUCTED W AGCORDAPICE WfTM
. e. WA7ER LEVEL Eelow Tep of Casin�. � FT 15P �SCAC 2C, wE�� GON97AUCTCN , AND THAT A COPY QP Titl$
(US8 "�` i1 Above Top c! Casing) RECORO w�, eEEN GROViDED TO 7HE wEIL OWNER.
d. TOP OF CASING IS ____� F1'. Aeove Land S�uiaccr' ��,��(,,, _ 3� /�
'Top of cssing terminated aVOr betow land surface may r2quire «=--�`
a variance in accordance with 15A NCAC 2C .�119. SIGNATURE OF CER IFIEp L CONTRAC70R DATE
e. YIELD (gpm); � : METHOD OF TEST �iI_/`�i � / �v ���d �� �—
PRiNTEO Na��l� oF PER N CONSTRUCTING THE EL�
Submlt the orlginal to the Division of Water Quality within 30 days. Attn: Information Mgt., Fortn GW-ta
16�7 Ma[I 5arvice Centor — Ralalgh, NC 27699-1617 Phone No. (919) 733-7015 ¢xt 568. Rev. ��05