411955_Well Construction - GW1_20130304

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2 h 1 1
1. WELL CONTRACTOR:
Douglas Hewett
Well Contractor (Individual) Name
Hewett's Well Drilling
Well Contractor Company Name
STREET ADDRESS 2172 Ocean Hwy West
Supply NC 28462
City or Town (State
( 910- 77- `4=.6528
Area code- Phone number •
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)
)5S/i
79'�
DWQ or OTHER PERMIT #(if applicable) �E-
WELL USE (Check Applicable Box): Residential Water Supply kr.
DATE DRILLED /` '- /02-'
C
TIME COMPLETED : 3 ' 0 0 AM. ❑ PM'
3. WELL LOCATION:
CITY: 5Y,
...> �� FieicaPabriook Z.lv S t.t''
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑ Valley ti!at ❑ Ridge ❑ Other
(check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: D GPS ❑Topographic map
(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
W )/i- 5t//,04In
STREET ADDRESS 5,$" Lon.hecri t /- 4-144-1
Cityor —own( State ZipCode
( )-
Area code - Phone number
COUNTY Bra7.1,1)i c'
Zip Code
May be in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS: 71.71
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES k'"-NO ❑
/2)
c. WATER LEVEL Below Top of Casing: 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 (9P m) : METHOD OF TEST g l
f. DISINFECTION: Type ( M Amount / f
g. WATER ZONES (depth):
From To 71/From To
From To From To
From To From To
6. CASING:
y,e, Depth , .
From (...) . To Ft.
From To Ft.
From To Ft.
Thickness/
Diameter Weight M terial
7. GROUT: Depth Rely
Material
Frorrl�To- r�s Ft.
From 0 To 3 Ft. teii e b:
From To Ft.
Method
C -0c
t
8. SCREEN:. Depth Diameter Slot,Size
From To Ft. in. a) in.
From To Ft. in. in.
From To Ft. in. in.
M t:it
9. SAND/GRAVEL PACK:
De t • Size Material
From To 7y Ft. GOr v
From To Ft.
From To Ft.
10. DRILLING LOG
From To
/�.- D
3D — 4--H)
11. REMARKS:
Formation Description
5tc!
O/j4y
-�; 5 &
WATER QUALITY SECTION
8*1-DRMATiOi PROCESSING UNIT
1 DO HEREBY CERTIFY THAT THIS WEL
15A NCAC 2C, WELL CONSTRUCTION
ORD HAS BEEN P)tOVIDED TO
WAS CONSTRUCTED IN ACCORDANCE WITH
ANDARDS, AND THAT A COPY OF THIS
WELL OWNER.
/D51-ice
F CERTIFIED WELL CONTRACTOR DATE
Douglas Hewett
PRINTED NAME OF PERSON CONS1 U TINk h
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.
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