405529_Well Construction - GW1_20120611

RESIDENTJAL N' 'ELL CONSTRUCTION. RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2616 —AI-
:. WELL CONTRACTOR:
immV S. Quinn
Well Contractor (Individual) Narine
Quinn's Well Dr llinu
Well Contractor Company Name
3242 Potters Hill Rd
Street Aaa ress
Pink Hill. NC 28572
City or Town
( 252) 568-2380
Area code Nnone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
.. WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED
TIME COMPLETED , ' / AM Li PM
4. WELL LOCATION:
CITY: r Lath C O U N TYJ2iZP2-/ J1---
State Zip Code
)G 7
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
C1 S1ope LValiey LI Flat [_1 Ridge (]Other
LATITUDE 36 " DMS OR 3x.xxxxxxxxx DD
LONGITUDE 75 " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: BPS Lfopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) •
5. WELL OWNER +i a
R etytd-y
Owner Name
&WV ///
Street Address
/S&{L4Li (t / 4 ,
City or Town State
6.1/4
( 0) 24
Area code Phone number
6. WELL DETAILE
a. TOTAL DEPTH: 2
a. DOES WELL REPLACE EXISTING ING WELL?
c.
WATER LEVEL Below Top of Casino.
Zip Coae,
g. WATER ZONES (depth):
Top ' Bottom.. Top Bottom
Top/ l �. Bottom /20 Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight a%tera l
2,Top Bottom F. �fe
jt 0Top Bottom . fO2-Ft.
Ton Bottom Ft.
8. GROUT: Death
Too Bottom 20 Ft
op Bottom Ft.
Top Bottom Ft.
aterial
Met c
1
eiV
D. SCREEN: Depth Diameter Slot Size Material
Top j/2- Bottom / ° Ft._ in. /6— in. PPC
Top Bottom Ft. in. in.
Toa Bottom Ft. in.
't 0. SAND/GRAVEL PACK:
Depth Size ateriai
Top Bottom / 2—Ft. /Ile 4461,
Top
Top
Bottom/
Bottorrr
11. DRILLING LOG
Top Bottom
/�
Ft.
Formation Description
ele 0 5"/7WC.
12 2-
a l0, /1c
tr
JUN 11 20122 �zE��ARKs
(Use if Abov 4T-o of Casing)
FT
IS
d. TOP OF CASING IS FT. Above Land Surface'
;Top of casino terminated at/or beiow land surface may reoutr;
a variance in accordance with 15A NCAC 2C .0118.
jou/a
e. YIELD (gf,rn). 51- METHOD OF i'I✓ST/$.1
4
f. DISINFECTION: Type clef I^f Amount 4- j''�14-�
RECEIVE
jU4 217
g-
� P i UnitG
DW
i DO HEREBY CERTIFY THAT THIS WELL VVAS CONS�IRUCTED Iry
ACCORDANCE WITH 15A NCAC 2C. WELL CONSTRUCTIOI-
STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN
PROVED TO THEW . L . 5WNER.
'(GNATyR�
Vt
OF CERTIFI: s :LL CONTRACTOR DATE
ULYsi
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone] .
Form GW-1a
Rev. 2109