411441_Well Construction - GW1_20130211

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CON . TOR:
Well Cna oCd' dual) Name e
1 ife4 tile ne /6-",
r
We�ac CompanyName
de.,
STREE ADD S ;11
v /...ren
��f' 7��'�
cd Y.d/ �lL ACC r#2 D 6/71/
City o own ate 5--
Zip Code
/D ) - z - yfby
Area code - on number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) .
STATE WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check A licable ox): Residential Water Supply ❑
DATE DRILLED / /J
TIME COMPLETED :0-42 AM ❑ P114'
3. WELL LO TI1.:
74COUNT �✓
CITY
ii
(Street Name, Numbe , ommunity, Supervisor, Lot No., arcel, ip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope 0 Valley 0 Flat 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 form if not using GPS)
4. WELL OWNER et)i
OWNER'S NAME
STREF„T ADDRESS
17.4P 7-17
City or Town
0
/714
)-
Area code - Phone number
Ai&
State
5. WELL DETAILS: eifte,
a. TOTAL DEPTH:
Zip Code
qz,
b. DOES WELL REPLACE EXISTING WELL? YES 0 NQ
c. WATER LEVEL Below TopCasing of ' 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) 0-14"METHOD OF TEST
411441
4 I
f. DISINFECTION: Ty %4/ Amount
g. WATER ZONES (depth)
From To
From To
From To
6. CASING:
From To
From To
From To
Thickness/
Depth Diameter W i ht
From 0 To,7 Ft.4/ d
From To Ft.
From To Ft.
7. GROUT: Depth Material
From 0 To/ Ft.
From/a To /2, o Ft.
From To Ft.
8. SCRE • ,DeT(
Fro
From To
From To
Material
/vc,.
Method
fiot, r'
Di�rn�er S1Qit�ze
Ft.'' in. �' in.
Ft. in. in.
Ft. in in.
9. SAND/GRAVEL PACK:
FromD' ` 14;'!I. 4 Ft�SLIti ;me.
From To Ft.
From To Ft
10. DRILLING LOG
From
r
re. 7 // 7
/l7 <s"' L
6.S'L /ji
/fJ /J'7
!fia ip'2
r z
/Tr ;4e,'
11. REMARKS:
Fi Description
54W%
(5/
/45,
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piP/4'e
ti S7ane_.
d0/49e
4.7 ma_ S704 e_
s "of
WCYJUI •�
FEB 4 ti(1H::
information Pro ssing ;ii.
fWO/ROG
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 T. WE OWNER.
SIG ATURE OF CERTIFIED WELL CON tiT 'sDATE
PRINTED NAME OF PERSON CONSTRU _, NG(I" i LL.
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.
Form GW- l a
Rev. 7-05