411339_Well Construction - GW1_20130211

1. WELL CONT
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MENTIA WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL CONTRACTOR CERTIFICATION
tractor Compan a
STREET DD SS
City or own State
(WC') - 9 74€
rP7L'
Zip Code
Area code - Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable)
STATE WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Apyli ble Boy: Residential Water Supply 0
DATE DRILLED itt
TIME COMPLETED 5 447 AM 0
3. WELL LOCA ION:
CITY COUNT
'
ftee:#0,202ezels7
(Street Name, Numbers, Community, Supervisor, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
0 Slope 0 Valley 0 Fiat 0 Ridge 0 Other
(check appropriate box)
LATITUDE
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
(location of well must be shown on a USGS topo map and
attached to this fomi if not using GPS)
4. WELL OWNER
OWNER'S NAMIeeof/r/f in 1
STRE4AlrESS fryt ArP
010nd
City or Town State
)
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0
c. WATER LEVEL Below Top of Casing 571a7 FT
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS / 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) 30 METHOD OF TEST A
n" e4
mount
f. DISINFECTION: Type OU 46
g. WATER ZONES (depth)
From To From To
From To To
From
From To From To
6, CASING: Thickness/
Dep Dia e r Ma rial
From (t) Ft.'
From To Ft.
From To Ft.
7. GROUT:
Depth 'Material Method
From
From T2,01
Ft. 1.': ,- :,/
To :14ater
Ft. it
From To Ft.
Afr
8. SCRE ept1-42 n Q.,, Diawter Sle,ize e 'al
FF01 Tg7 r 1 Ft. ---A.----- in. .4) in.
From To Ft. in. in
From To Ft. in in.
9, SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From Tc Ft.
From To Ft
10. tRILLING LOG
From
$c
;44
14'
;to /
avgtst
FRA..ipr*Description
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avoy
ezote- 5 7224
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OD
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11, REMA
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011sto‘ 0,150 •
11
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C„ WELL CONSTRUCTION STAND : 11 S, AND THAT A COPY OF THIS
deRECORD HAS BEEN P ' JVIDED TO THE WE , - i ER. i
PRINTED NAME OF PERSON CO TRUCTING THE WELL
FEB 1 2013
Submit the original to the Division. of Water Quality within 30 days. Attn: Information Mgt.,
Form GW-1 a
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568. py

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