412574_Well Construction - GW1_20130408

d\ESP1/-ENTI-- WELL CONSTRUCTION RECORD
North Carolina Department orEnvironment and Natural Resources- Divisio of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTVM:2`cip3C
WeD Con )actor (IndividuajName
SITE WELL ID #(if applicable)
e
Well Conk for C pant' Name
7 L' LO \CJ-hef (e_c
Street Add((r\ess
W)(� \1kiNt "5� \ t vag
I/(
( lle)Town
2)I
code State Zip Code
Area cde Phone number
2. WELL INFORMATION: t 2
WELL CONSTRUCTION PERMIT# ,j . f _,) -. QIN
OTHER ASSOCIATED PERMIT/kit applicable)
i c p Q
3. WELL USE (Check ApplicablegJox): R dential Water Supply Er
DATE DRILLED "— ) �g
TIME COMPLETED i d (j)
4. WELL LOCATION:
CITY: Mom ysi
Go t \ t Y6 N L-n .Qggi 5
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other
LATITUDE 36 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75 " DMS OR 7X.X10tXX00t DD
Latitude/longitude source: £ PS propographic map
(location of well must be shown on a USGS topo map enda#ached to
this form if not using GPS)
AM ❑ PM02�7
COUNTY
5. WEL c/ ER `s Ric CMG, Fd ei I;
OWner Name -tom
Street t4dadresn^ �s4ext d � l(L
, r
\I�YigrTawnt(/�.„) a'l 1 7� State Zip Code
(LArea code Phone number 11
6. WELL DETAILS: iTh
a. TOTAL DEPTH: 1 c 0
b. DOES WELL REPLACE EXISTING WELL? YES ❑ Nn
c. WATER LEVEL Below Top of Casing:— I FT.
(Use "+" if Above op 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): MET,UOD OF TEST
f. DISINFECTION: Type I n) 1 O(Amount
g. a'�ra rR ZONES(dept
Top w Bottom (, Top Bottom
Top ��/_Lr� Bottom— Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING Depth Diameter Wei ht M dal
Top ottom ^ I Cot.
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth n Materiel
Top Bottom FL DCl-®11n
t4C
Top S Bottom( t. 0 -%. 1O(.,( r
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top Bottom FL
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
Top. B F . Hon r -scaption
El
ASKISItaillina
(
!MESSING UNIT
12. REMARKS:
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
PROVIDEDIL THE se,O `
jt�iv(/
c
5- 13
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699.161, Phone : [phone]
r ) ,area_ I(In,ld
Form GW-la
Rev, 2/09