411951_Well Construction - GW1_20130304

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2611
1. WELL CONTRACTOR:
• Douglas Hewett
Well Contractor (Individual) Name
Hewett's Well Drilling
Well Contractor Company Name
STREET ADDRESS 21 72 Ocean Hwy West
Supply, NC 28462
City or Town (State Zip Code
q10- 7&4=:..528
Area code- Phone number •
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable) .2C)0 / O /gcc)
WELL USE (Check Applicable Box): Residential Water Supply -'
DATE DRILLED
TIME COMPLETED AM❑ PM [IV"
3. WELL LOCATION:
CITY.
- -b hOS X COUNTY 8v-'rsg'-" e1/4
�f32 ('hPz 1-n t °pit
/Y&.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑ Valley 0 Flat 0 Ridge 0 Other
(check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source:
May be in degrees,
minutes, seconds or
in a decimal format
❑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
USSe//
OWNER'S NAME LAtorehe -e
STREET ADDRESS 4 .' 8,,a.-/- Or•
Ct/jd5I.i We- 2.�
City or Town State Zip Code
( )-
Area code - Phone number
• � GLL DETAILS:
1 NII_J 5. WELL DETAILS•
a. TOTAL DEPTH: �1")
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: FT.
(Use"+" if Above Top of Casing)
d. TOP OF CASING IS r . 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): r--S METHOD OF TEST tlinip
f. DISINFECTION: Type P Amount / /�
g. WATER ZONES (depth):
From 30 To 0 From To
From To From To
From To From To
6. CASING:
From 0
Depth
To Ft.
From To Ft.
Diameter
From To Ft.
7. GROUT: Depth
From 0 To g
From 3 To? 0
From To
Thickness/
Weight
Scl4d
Material
Ft. e-egAmi-e...
Ft. 63 r. off..A.
Ft.
M/6e`i
8. SCREEN: Depth Diameter Slot Size M ;yid
d
From 3� . To- Ft. in. r-20 in. ...-
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From Z TocS Ft. 2 a- f Ave /
From To Ft.
From To Ft.
10. DRILLING LOG
From To
0 - �a
11. REMARKS:
Formation Description
C/y
19N
5 5P4e,e__
EH 2 5 ?in
WATER QUAL�-IT�f 7,,CCTI0N
INFOE�i�' ATi 1P,c.i :0CESSi �G UNIT
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL ONSTRUCTION STANDARD ., AND THAT A COPY OF THIS
ORD HAS BEE [ ROVIDE i. '• THE WELL NER.
5-42_
I, NAT E F CERTI 1E ELL CONTRACTOR DATE
Douglas Hewett .f j?°�
PRINTED NAME OF PERSON CONSTRL! TiNG THE WELZ
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.
MAR42Ol3
Form GW-1
w, Y,. Rev. 7/05