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A39 32�� 9� ��.�`�� _ —' s � ��T� 'n '�7�.��'n'n'r'"-n � .^i��.� �cLa�.�ll.� W � e ' a - ��$d19'BH� - PL�E SEE �'�.'��D i'Y.Alii �dJI� "W�EI�. SY'I'� I.�1`��iJ'�' T� nr�� #: � 3 g �� # � �o�� ,� s�a��: _ s�uo�: �� S . � t�� L�� e� � R� ° �r� Q�Ir►�� ,� ._ , - , ' ; ;�'. ,�, 1,. • • � •� , ♦ r� n • . � � 4 � .- � : l�Cec��a�dreffi�agffi• Site A�proved by,�� 5-1q-o� Grouting proved by ✓ S�r q"03 Well I.og - o- �Oell Tag - Air Ven.t � Hase B� ' COIICI�tC S� 1�� .- .1: � . : •. , - . ':: . :�; , '�ee 1�ttacflae� Si#c 5�et�h�` Wells must be 10 feet from propertp Iiaes. Wells must be 100 feet from septic systems. WeILs must be at ieast 25 feet from anp bu�ding foundatian. Other conditions- PC.��, se�v. 09/07/01 � 05/2�/2003 07:09 4773708 �e ��--��5� I�I��.�� ! � � � �� I�.aa�a�-�a.�uu�.�.��n�„�11 ��I.�J.Ea Ownez�: � Locarion: ,,.,� Subdivasia�; HUDSON WELL CO Driil'I�.�r IQ # Cor�Ta;��niy N��n�c . D•t�t�e Drilfee! We11 �og I,ot # Tax Map ParceI # 'Well Constructi n Uist�nce From nearest 1'roperty Line (Minimum 10 feet) 1 a Distance from Septic System (Mizxi,mum 60 feet) L� 0 Total Depth.: 5$' S_ ft Yield:� � GPM Static Wat L�vel: _-30 - ft Wate� aearing �ones: l�eptl�obl� ft #t ft ft Casing: $'`� Depth: Fram _� l__ ta �,,,_ ft. Diameter: �O ` in Ty,pe: Galvaz�i.zed Stee� ✓ Weight: . Ul$Ti Thielrness: j b Height abvve Ground; �a uz Drive Sboe; �Xes No ,A.�a.y prvblez�as encauzxtered wb.ile setting casin�? Xes �o If `�+es" give reason: PAGE 01 Grout: Neat: Saa,dJCemer�t �/ Concrete GraveUCement Annular Space Widtb ��, incl�es Water in AnnuIar S�ace _ Yes r No Method of Grout: Pumped Pzessuze Pc�ured � Deptb. � to�e ��'� Mate�i�s Used: No, Bags Pozta,and cem�nt �� Weight of 1 Bag ��, pounds If mixture (sand, grav�l, cuttin�gs} - l�atio �t�., to / ID plates: �Yes � No 4 x 4 slab _'Yes ____ No Drilli�tg Log Locatio�n D�awxng Frn,m To �'vxmation � � Z � � � n' r , 4 Q � $ � �� I OI� � hereby certif}r tb,at tb�.e above iz�formation is cozzect amd that this well was constructed ia� ac�oz�dance with regulations set foc�th by the Person County Health Ue�aztczxez�t. Si�pature of Contractor �� (� 1�FC�11 �C!] YU #.�. 4� Date o� � 7' d� �CkiD rev Ol/16l02 ��,;;�� "'� � �L.J �� 11 7Eua�-as-��*�+TMTM*a�aa.��.lL ��.11�]la � 5��. �� Name � ,��1 � 1 . Subdivision Authorized State Agent Tag Map # � ��.Parcel # 3� Section/Lot# �-f�-D � Date System components repr�esent approximate �contours only. The contractor must, flug the systern prr.'or to beginning the irisiallativn to insure that propergrade is maintained � . �j'� �1�1 I � � � Scale: a � �rav� � j ra� �o� �lt� � � �� S�}' �' � � i Pcu�� - . � � Q� C,�� Y�� C1� � _,�u �- � I � ��n �LG.'� �r� � ' `'�. � Co�,�� n�— ��a-�-Q ST a� ��;,� l; �PS.