411954_Well Construction - GW1_20130304

RESIDENTML WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources Division of Water Quality
WELL CONTRACTOR CERTIFICATION It '2
1. WELL CONTRACTOR:
ag_utaia_s_ Hewett
Well Contractor (Individual) Name
evelet t
Well Contractor company Name
STREET ADDRESS 21 72 Pcean_ liwyKagt.
Silppl yr No_ 8 4 6_2
City or Town State Zip Code
L....01Y _7574 28
Area code- Photie number •
Z. WELL INFORMATION:
SITE WELL ID it(if applicable)
STATE WELL PERMITikil applicable) _ _-
DWQ or OTHER PERMIT ti(f applicable) 214/0 a 2D ye .1(
WELL USE (Check Applicable Bex): Residential Water Supply (to.'
DATE DRILLED
TIME COMPLETED 51 Atvt
3. WELL LOCATION:
CITY: 5 COUNT Helms:La/4
rrLM
.41
(Sb-oet Name, Numbers, Community. Subdivision, Lot No.. ParcEi, Zip Colt*
TOPOGRAPHIC ILAND SETTING:
°Slope (Valley 13Plit 0 Rkige 1:101her
(chock apptopriais box)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
- -e
Latitude/longitude source: OOPS El Topographic map
(location of well must be shown on a USGS topo map and
attached to tigs, form not using GPS)
4. WELL OWNER
OWNER'S NAME 144111:k so
STREET ADDRESS oC" 7-7.4t
City T
(---
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
110*
State
72-41YA
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES CI NO
c. WATER LEVEL. Below Top of Casing:
(use .4,2' If Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface*
. *Top of casing terminated aUor beliav land surface may require
a variance in accordance with 15A NCAC 2C .0118,
e. YIELD (gprrl): Ica' METHOD OF TESTH, t
1. DISINFECTION: Type
g. WATER ZONES (depth):
Rom To /
From To
From To
6, CASING:
From E,} Ft.
Depth of.% ..Dixnete_r ftgt±.eiA
cr-4,74a
From To Ft.
1 1954
AmountYtS
From To
From To
From To
Thickness,
From _ To Ft.
7. GROUT: Depth Alaterlal
From 0 To 3 Ft EC-Ekrup
From To 20 Ft.
From To Ft.
Method
8. SCREEN: Depth aterialDia' meter Slat Size M
From •To FL Jn.
From To Ft in. In.
Froni To Ft. in. in,
9. SANDIGRAVEL PACK:
Depth
From To FL
From
From
Size Material
To Ft,
To Ft.
10. DRILLING LOG
From To
757-1775-
11. REMARKS:
Formation Descriptktn
1---B 20H
•
WATC CVA,u71
I DO HEREBY CERTIFY THAT THIS WELL WA5 CONSIRUCTED IN ACCO.RDANCE wm
15A NOM 20. WELL CONSTRUCT1ON ST DARDS, AlD DATA COPY OF Th1S
RE -CORD HAS BEEN ED TO ELL OWNER.
SIG
WELL CON"rRACTOR DATE
JX)palaiigligilatit
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: tnforrnation Met.,
1617 Mail Sorvtco Center — Raleigh, NC 27699-1S11 Phone No. [phone] ext 668.
17\ KA,
Form GW.1a
MAR 61113
IT