411442_Well Construction - GW1_20130211

R
ESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
We C. �trac o"r (Individtia1) Name
1/P4 WI/ I A/111/1 f
Well Con actor Company Name
STREE AD SS
frof ACf al c4
0 tat e N.G Ss 7 z-
61fD
City gr Town State
c l ) 64I ?PAC -
Area code - Phone number
Zip Code
2. WELL INFORMATION:
SITE WELL ID # (if applicable)
STATE WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applic le x): Residential Water Supply ❑
DATE DRILLED /17/1/2..
TIME COMPLETED T • 6ra' AM ❑ PM
3. WELL LOCATION:
CITY /.04,
/�� te At 4ted
�YCyV
1wet' it DDr`
(Street Name, Numbers, Community, Supervisor, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑ Valley ❑ Flat ❑ Ridge ❑ 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 form if not using GPS)
4. WELL OWNER
OWNER'S NAME(1_,(Ofl4
STREET ADDRESS "77 / a( Aton.,12/4/
/ )Ci 6011,-(A4vtaxe, Ace S-ci
City or Town State Zip Code
( )-
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
zz�
�a J
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO [�
c. WATER LEVEL Below Top of Casing id, 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) ,e7 METHOD OF TEST 4,.
11. REMARKS:
411442
f. DISINFECTION: Typy
g. WATER ZONES (depth)
From To From To
From To From To
From To From To
41 Amount
6. CASING:
Depth, Diameter
From C Too/ s Ft. 2,
From To Ft.
From To Ft.
Thickness/
W 'ght
,CYO
7. GROUT: Depth Materi 1
From To/0e, Ft. 00417MtgrZ
From t To 4 Ft dente“--f
From To Ft.
8. SCREE• Depz4 Diater
Fo ""'� r nie To
From To
From To
9. SAND/GRAVEL PACK:
Depth
Fro� � � T�
From To
From To
10. DRILLING LOG
Gs�
Material
Method
S1o�Size Material
Ft. in. d in. v
Ft in. in
Ft. in in.
From To
O 3s
.7 4 0
7Z. Z
// 7 //
//
/Z7 /4#4
/ 7
Ft.
Ft.
Ft
Material
F ation Description
49,020/
twir
Cc:/ice S Tavu-
# of
lc,'me 5 7-2).2.e.
,r4 2 -e
.San�oC
7f• /7 te.- Sroe/
20 Z - Sao of..
C I "•k E
X'
FER ij .',Oil
,;Tforr `tatton Processing Urij(
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 PRIDED TO THE WOWNER.
SIGNATURE OF CER
PRINTED NAME OF PERSON CONSTRUTIN
�i
etIWElt 2013
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Rev. 7-05