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NOTE: Make sketch �stallat�o lot size and sha�location of hous�, septic tanks, privies, water
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NORTH CAROUNA DEPARTtAEtJT OF NATURAL RESOURCES A�aO COMMUNITY DEVELOPMENT
DIVI9ION OF HNVIRONMEN7AL lMNAGF.MiF1�T ' GA�NDWATF�t SECTION .
P.O. BOX 2798T � RALE1(iH,N.C. 2T011, PHONE (87B)733-3221
WELL CONSTRUCTION RECORD
� � i%% �' /�,. /%� � •
DRILLING CONTRACTOR '�
nctll I FR REGiSTRATION NUMBER .
1, WELL LOCA710N: (Show sketch ot the location below)
� " Neare Town:
'� /
� ro„�.� �^.nmmu v. or Subdivision and Lot No.)
2, pWNER
AODRESS � ( treet or R ute No.)
� .;►,,1,1��;. jL,c � ? 7D�
�- Slate Zip Code
fCit ar 7own
3. DATE DRILLED /�� USE OF WE�L
. CUTTINGS COLLECTED ❑Yes No• •
4. TOTAL OEPTH � •
5. DOES WEIL REPLACE EXISTING WElL1 ❑ Yes
No
�_ FT. �, �e TOP OF CASiNG,
6. STATiC WATER LEVEL: �y�oelow
/ FT. ABOVE �AND SU FACE.
TOP OF CASING IS �L--- ,
'. YIELD (9Pm�= � METHOD OF TEST
>. WATER ZONES (depth): � �
_��-.G1-- Amount
.°, CHLORINATION: TYPe
'. CASiNG:
Wall Thick�Fss Mater' 1
' . DTohv Diag� er or We�t.
�Ft. � ,�
From �- . •
From To �Ft.
From To Ft.----
— _------------- �
FOR OFFICE USE OWLY F.'
,'
�uad. No. ' Serial No. --•�
Lat.
Lonq. P� -- r,.
Minor Baeln —
easin Code
Header Ent. ' GW-i Ent._-`�
.�
_ �.
STATE WELL CONSTRUCTION ' -
PEAMIT NUMBER:
Jounty: �
Depth
From Ta
D �7 �
� -
a�-63
�D�-o�00
�----
DRILLlNG LOG
Formation Description .
t t. GROUT: Material Metho .
O epth _�
From � TO-�`�Ft.
From Tb —Fl.
SCREEN:
Oeplh Diameter
Slot Slze Mate�ial ' ,
�:
It additional space is needed use back ot tortn..- .?
LOCATION SKET H
(Show direction and distance Irom at least lwo State Aa, *��
ot other map reterence points) ��
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+ 1'
From To —
FI. in. in. �
in. in.
From ' To — Ft. _ � f�M
From
To — FI, in. ,
,;t. GRAVEL PACK: ht�tenal
Oepth SiZe
From
To Ft.
From To Ft.
!.: •iEA1�F�KS:
1 DO HEREDY C�ATIFY TH:�T Tf�15 �`ELL ���S CONSTRUCTEQ �N
ST,�NUARDS. ANO 7H.�T .i LCPY ��F TNI� FECOR �i �
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pWNER.
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