GW1-2021-01488_Well Construction - GW1_20210429

6 gym,
t RESIDENTIAL WELL CONSTR
UCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3131
1.WELL CONTRACTOR: g. WATER ZONES(depth):
L.O Y-% Top Bottom ! Top Bottom
WellContractor(Individual)Name Top Bottom r Top Bottom
'1►.te -S LztL >f"j,u%Ra , l nr,• Top Bottom Top Bottom
ell Contractor Company Name J
Thickness/
I4W2 CR1wi: lR;Age. gt-1 7. CASING: Depth Diameter Weight Material
StreetAddress Q I
Top Bottom 136 Ff.
�I0.1TSUttlF GA Top
Top Bottom Ft.
City or Town State Zip Code Top Bottom Ft.
7( oty) -7qe- 21 Lola
Area code Phone number 8. GROUT: Depth Material Method
2.WELL;lNFORMATION: Top Bottom -�.0 Ft.
WELL CONSTRUCTION PERMIT# Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(ir applicable) Top Bottom Ft.
SITE WELL 1D.#(If applicable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply Top Bottom Ft. in. in.
DATE DRILLED T -1`i!'— 2 Top Bottom Ft. in. in.
TIME COMPLETED qe 3O AM El PMX Top Bottom Ft. in. in.
4.WELL LOCATION: ` 10.SAND/GRAVEL PACK:
CITY: !il' COUNTY C/'.(/l er4�e�° Depth Size Material
Top Bottom Ft.
P iy e l wa D r t V e f 'Zg g O6 Top Bottom Ft.
( treet:Name;Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) Top Bottom Ft.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Sloize ❑Valley ❑Flat Ridge ❑Other
11. DRILLING LOG
c Top Bottom Formation Description
LATITUDE . 36.0 �2d At DMS OR 3x.xxxxxxXxx DO / ATI3 ro wn d r t
LONGITUDE g,�° (y5 v►/ "DMS OR 7x.xxxxxxxxx DD 1?ro n iS e 1'i"7-
Latitudeliongitude source: (BPS Wropographic map
(ICcaftn.of well must be shown on a USGS topo map andattached to
this folin°if not using GPS) 6-5 l f O 0 / P
S.WELL<OWNER ( eo' ,® I QD/ l3 D Ciro W SQ YId Q�e
rt.
/ 625 e
Owner Name
Street Address
City or Town -State Zip Code /
Area code Phone number
12. REMARKS:
6.WELL DETAILS: `
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑ I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT, ACCORDANCE WITH 15A NCA'C 2C,WELL CONSTRUCTION
(Use"+"9 Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PR ED TO THE WELL OWN
d. TOP OF CASING IS FT.Above Land Surface*
*Top-of casing terminated at/or below land surface may require y �('2�
a variance:in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED ONTRACTOR DAT
e. YIELD(gpm): . ClL METHOD OF TEST
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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