412575_Well Construction - GW1_20130408

1. WELL CO
RESIDENTIAL WELL CONSTRUCTION RECORD
North Caroiinu Deportment of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 41 V -A
mh Ii ACC
Well ;In or jlndivid Minn
oniractor Com ay Name
!L) (__C�1U(�•+ncy P;Qnc oc
Street IAd Address
t I i 7' 0 AC A 3 t i;
Cit_•orvTown Stale Zip Code
Area code Ph
2. WELL INFORMATION: `"? ` c\ ry I
WELL CONSTRUCTION PERMIT#I l`Vi (�J U '-jf
OTHER ASSOCIATED PERMIT#L't_ (Ir applicable) ) } tee). (
SITE WELL ID Nirapplicable)
3. WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED'", t� `' `�J
TIME COMPLETED I k00 AM ElPM a./
4. WELL LOCATION:
CITY:
,0e
( treat Name, Numbers,
COUNTY
ommunily, SubdMelon, Lot No., Parcel, p Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
oSlope ❑Valley ❑Flat 0 Ridge ❑Other
LATITUDE 36 "DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75 ° "DMS OR 7X.XXXXXXXXX DD
Latltude/longitude source: OGPS ❑topographic map
(location of well must be shown on a USGS topo map andattached to
this form If not using GPS)
lox f.JNELLO {�,1 \ id_ \s" \ c_�
mYet)
soo(
`Pow
1N111 et) 0 60 (�
' C1 +r
Street Addres
H&n°iHS 0N)C ee`gee
^r Town74./ �/-/, State Zip Code
Area code Phone number
6. WELL DETAILS: I
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: " FT.
(Use "+" if Above op of Casing)
d. TOP OF CASING IS 4- FT. Above Land Surface"
"Top of casing terminated al/or below land surface may require
a variance in accord noe with 15A NCAC 2C ,0 18r I
e. YIELD (gpm): ) M THOD OFF " `TEST"
L-�+
I p
f. DISINFECTION: Type cAmount Rib<
g. W TER ZONES (dfe ):
Top 9 Bottom ( Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth �1 Diameter C+We ht ateriai
Top Bottom 100 Ft. f SC411-10 V
Top Bottom Ft.
Top Bottom FL
8. GR UT: Depth M'aterial
Top Bottom S Ft, IiC9q 140
Top" Bottom 'eXL.' FL
Top Bottom FL
9. SCREEN: Depth
Method
FMcfi
Ui- Ems;
Diameter Slot Size Material
Top Bottom Ft.
Top Bottom Ft.
Top 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
/-
12. REMARKS:
ma •n Description
c.avrarinnammit
str'.+. I-'e S-i-rune
EG'TI©t'
04, i
1 DO HEREBY CERTIFY THAT THIS W WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONStRUCfiON
STANDARDS, Ai(VD THAT A COPY OF THIS tFGORD HAS BEEN
PROVIDED T, WE OWNER.
a age
PRINTED NAME OF PERSON CONSTRUCTING HE WELL
SIGNATURE OFtERT(FIEiiWEL CONTRACTOR D
Submit within 30 days of completion to: Division of Water Quality - information Processing,
1617 Mali Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-la
Rev. 2/09