411948_Well Construction - GW1_20130304

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2 61 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 tate Zip Code
( 910- 754 4528
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)I L/ . U7 /0 ES)
WELL USE (Check Applicable Box): Residential Water Supply EV-
DATE DRILLED " r 4., 4-21
TIME COMPLETED ' D 0 AM. D PM f
3. WELL LOCATION:
CITY: COUNTY
46 &IJi?sf.''C
(Street Name, Numberst{ommunity, Subdivision, Lot No., Parcel, ZipCode)
e)
TOPOGRAPHIC / LAND SETTING:
D Slope D Valley D Flat D Ridge D Other
(check appropriate box)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: D GPS D 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}1( Pe/1�' 4'
STREET ADDRESS /ba39' ecAd , f d
co ha 46,k- /// -2 Wc.
City or Town State Zip Code
Area code - Phone number
5. WELL DETAILS: /9Sr
a. TOTAL DEPTH: l
b. DOES WELL REPLACE EXISTING WELL? YES "NO D
c. WATER LEVEL Below Top of Casing: 2
9 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 (gpm): /0 METHOD OF TES 1.
1 1 9 4 8
f. DISINFECTION: Type 11 / l— Amount / /1
g. WATER ZONES (depth):
From O To /sIS r From To
From To From To
From To From To
6. CASING:
Depth Di eter
FromTo �E" Ft.
From To Ft.
From To Ft.
7. GROUT: Depth
From 6
From S
Thickness/
Weight Material
Material
To 3 .e
Ft. e�w e
To_2.0 Ft.
From To Ft.
8. SCREEN: Depth
From To
From To Ft.
From To Ft.
9. SAND/GRAVEL PACK:
Depth
From
From
From
Method
Diameter Slot Size Material
Ft. in. in.
in. in.
in. in.
Size Material
To FL
To Ft.
To Ft.
10. DRILLING LOG
From To
70
/6— 3-5-
?r-
//5 o
/op— / 2
5-67
/3'-c'--
/61)e)
11. REMARKS:
FEB3
WATER OUALiT ..., .,0N
INFORMATION PROCESSING .0
Formation Description
/Itar c 47A�
Sad % �l,P�l /1o&(
C/L,,1%a c /7
Oe it
UeCclt_yc
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WEL NSTRUCTI STANDARDS, AND THAT A COPY OF THIS
HAS BEEN I OVIDED TqT iE WEER.
SIGNATUFOF CERTIFIED WELL CONTRACTOR
Douglas
Hewett
H%��.C•.1MY
PRINTED NAME OF PERSON CONSTillg:CTING THE WELL
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. (919) g
919 733-7015 ext 568.
`U. T
,re a.AR i;t 1.131,)
�j N
Form GW-1 4"'
4IT