411942_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 2172 Ocean Hwy West
Supply, NC 28462
City or Town State Zip Code
( 910- 7:54-6528
Area code- Phone number •
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)2 O/,2O 7j/,7
WELL USE (Check Applicable Box): Residential Water Supply Er-*
DATE DRILLED.—--�
TIME COMPLETED 13° AM.Q PM L9V
3. WELL LOCATION:
CITY: 3Pii
73fiiSi'C4-
OUNTY
Street Name, NumbE, Community, Su✓dMston, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑Valley ❑ Flat ❑ Ridge ❑ Other
(check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: p 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•
' IZA/%
i wz
OWNER'S NAME
(
May be in degrees,
minutes, seconds or
in a decimal format
jNPb�
STREET ADDRESS 2-ID m D %e &ai'4
;Z 2 2
City or Town State
( )-
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES V NO ❑
c. WATER LEVEL Below Top of Casing: /..2 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
Zip Code
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST 1)A
e4.: LI_ 4 2
f. DISINFECTION: Type T P Amount f l6
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING:
Dept— Diameter
From i) To Ft. 2
From To Ft.
From To Ft.
7. GROUT: Depth
From ® To 3 Ft.
From 3 To '20 Ft vA a "VI A-LI
From To Ft.
Thickness/
Weight Ma r
Material
FP Se.
Method
8. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
,2y- 3.5_
4'S
11. REMARKS:
Material
Material
Formation Description
13
1.[tfATER QUAI frY SECTION
hli�r,;��:�, y►-� � PROCESSNG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
D HAS BE ROVIDED Ti THE WELL OWNER.
SIGNA'*'' E OF CERTIFIED WELL CONTRACTOR DATE
Douglas Hewett Fx ;, �,a .u,..,•
:
PRINTED NAME OF PERSON CONSTRUDRI
k,•.y
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.
R plir20131al
Rev. 7/05
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