407695_Well Construction - GW1_20121001

WELL CONSTRUCTION RECORD
,A. Pa', 0 mi..
27699-1636 Phone No. [phone], within 30 days.
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Larry Williford CERTIFICATION # 2863
WELL CONTRACTOR COMPANY NAME Larry Williford's Well Drilling PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if a licable if a• . licable
1. WELL USE (Check Applicable Box): Residential Municipal Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIO : Nearest Town: W l e e covnty DlApii"r1
A ;-101 hAvg rad t• _Ike(
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OOWNER:C4d 8pckeP?
Address l 'I'7 i'vehbarg ris
Wck?l4t r(s��� Na.) eii66
City or Town State Zip Code
Area code- Phone number
4. DATE DRILLED — 02 5
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES D NO IF(
7. STATIC WATER LEVEL Below Top of Casing: 3 t FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with iSA NCAC 2C .0118.
9. YIELD (gpm): '�% METHOD OF TEST pW n 13
10. WATER ZONES (depth): /' 1-) / 5
11.. DISINFECTION: Type &ift
12. CASING:
,., Diameter
From "— Depth l Ft o
From To Ft.
From To Ft.
13. GROUT:
From
From
Amount
Wall Thickness
or Weight/Ft. Material
5 410 P
Depth Material
Togelittotter F�.
To Ft.
14. SCREEN: Depth Diameter
From, It. 1 To /i5 Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Size
From le Depth // SJ Ft. -Pr?'
From To Ft.
Method
pcUtr
S[i�ot Size
/1 • j 1-- •
n.
in.
.5q/2 tael`
Mate,
Topographic/Land setting
®Ridge ❑Slope ❑Valley at
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:DGPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
it
/... yr
1-49-
6 0 -r4„
/0,�_//sA...
e ''
act y
1 Cfa
/
C/et
/4 c, 1.s A c la
i-4,1 .s- ,p) -
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
tse \\
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE -WELL OWNER
; -, 2
SIGNA OF PE ON CON UCTING TE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Sec n,1636 Mail Service Center Raleigh,lyictj Li 3 1 2012
OCT o 1 201fw 07/2001
BY: