408835_Well Construction - GW1_20121022

Sltegl Address StreQt Address
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #1-1) - A
1. WELL� NTRCTOR:
frN
Well Contractor (Individual) Name
c Dr%oa t.4dyilt 5ervke.5 5
Well Contractor Comp Name
risiqCufeJ9
Street Add ess
401\ A/C 944914 Or
City or Town State Zip Code
(
110 ) g3J&1
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# vQorto7 q1
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply E]
DATE DRILLED CI— 2(.1"10
TIME COMPLETED (9‘, C7
•
•
4. WELL LOCATION: •
CITY: W 1) wig 1"OA COUNTY WewHtxtov.v' •
536\1 543, r4e 61— Lo4:qo -5ec Ji or► E -PairsneaK
(Street Name, Numties, Community, Subdivision, Lot No., Parcel, Zip Code) ?IV :
AM ❑ PM i!eK
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
D Slope o Valley ©Flat o Ridge DOther
LATITUDE 36
LONGITUDE 75.
" DMS OR 3x.xxxxxxxxx DD
" DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: EJGPS DTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
aletrIt5 5c.h\M'c
Owner Name
11(44 Bald 64‘ Lre
),;t,4i7,,
City or TowlY
(SW ) A°91310
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
(45 f+
C2ell I (
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES I� NO ❑
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS Of FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST bIOJ Uf.
f. DISINFECTION: Type Amount #X Lb.
•
•
35/ —+-I5
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
g. WATER ZONES (depth):
Top ' 3 5 Bottom �J
Top Bottom
408835
Top Bottom
Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
)t..cH40 C.
8. GROUT: Depth Material Method
Top d Bottom 3 Ft. bt t nr tke 4,61e+5
Top Bottom — aa Ft. OF 4-re";
Top Bottom Ft.
9. SCREEN: Depth
Top
Top
Top
Diameter Slot Size Material
Bottom Ft.
Bottom Ft.
Bottom Ft.
in.
in.
in.
in.
in.
in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
/ — S + Skald
jS / cv.,, C! stj
/
1
/
1
Lime to
OCT 1:aci2
CENTR'L FIL„
BY:DOITEREBTrERTTFTTITAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, ELL CONSTRUCTION
STANDARDS, AND THAT A COPY ., THIS RECORD HAS BEEN
PROVIDED S,O T ELL OW ►. R.
SI NATURE OF CE'' IFIE,p WELL CONTRACIIOR DATE
•
PRINTED NAME OF PERSON COSa
NSTRUING THE WELL
Submit within 30 days of completion to: Division of Water Quality
1617 Mail Service Center, Raleigh, NC 27699.161, Phone : [phone]
Information Processing,
Form GW-la
Rev. 2/09
AJftC - 7a6 9