GW1-2021-00933_Well Construction - GW1_20210305

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err q RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-`Division of Water Quality
:� WELL CONTRACTOR CERTIFICATION# 3 I S l
1.WELL CONTRACTOR: f. DISINFECTION:Type1h1Q11Uee Amount O O,Z.
L-on c).1\IOVA g.
WATERZONES(/da� �
Well Contractor(Individual)Name From?ND
From—To
Eg-r5 /WCADr�� in , [Y\C, From To From To
Well Contactor Company Name From To Fran To
STREETADDRESS �l-{�Z.AR�Lo. el�clua, IA7V 6. CASING: Thickness/Depth D Material
R�ci\r5V 1I U, CA 3c6lz F=VL/r— Ft.l%a � ✓E%
City or Town State Zip Code From To Ft.
f rnm- ►1 L4 _ Z I Lr LQ Fran To Ft.
Arm code- Phone number
2.WELL INFORMATION: 7. GROUT: Depth Materiat Method
From O Tc 2 y Ftx::�/LLdiL, �/�✓ ?
SITE WELL ID*(if applicable) Fran To Ft.
STATE WELL PERMIT#(d applicable) Fron(_To Ft.
DWO or OTHER PERMIT#(If applicable) 0. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply Fran To Ft._In. _ in.
Fran Ta Ft._in. _ in.
DATE DRILLED(1112.L I ZDZI Fran To R.—In. _ in.
TIME COMPLETED AM❑ PM❑ g WWDIGRAVEL PACK:
3.WELL LOCATION: Depth Size Materiel
CITY: 0.V-f SU l COUNTY c L oy From To Fl.
2U 13irq huP yil From From—To Ft.
(Street Name,Number,Community,S Asion,Lot No.,Perel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10. DRILLING LOG
CSlope CVelley ❑Flat ❑Ridge ❑Other From To Formation Dmcr Ion
(check appropriate box) May
.S6`/
LATITUDE May be m degas,
� _ minutes,sewnds a
LONGITUDE in a decimal format
G� Seri �.aN7e
Latitude/longitudesource: ❑GPS ❑Topographicmap
(boation of"I must be shown on a USGS topo mop and
attached to this form Inot using GPS)
4.WELL OWNER
OWNER'S NAME
STREET ADDRESS
MAP,
City or Town State Zip Code
Area code- Phone number
II. REMARKS:
5.WELL DETAILS: _
a. TOTAL DEPTH: 34�5
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOX
DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE W RH
C. WATER LEVEL Below Top of Casing: _FT. ISA NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
ve(Use'+-if Abo Top of Casing) RECO Q SBEENPROVIDROTOPEWE OWNER.
�d. TOP OF CASING IS FT.Above Land Surface' 2-2Z -2/
-Tap of casing terminated at/or below land surface may require ATURE OF CERTIFIED WEEL CONTRACTOR DATE
a vanance in accordance with 15A NCAC 2C.0118.
e. YIELD(gpm): �ZO METHOD OF TEST A•tr LO'n�iQ'C�
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-ta
1617 Mail Service Center—Raleigh,NC 27699-1617 Phone ND.[phone] ext 888. Rev.7/06