GW1-2021-01489_Well Construction - GW1_20210429

SrA1E,*
- _ RESIDENTIAL WELL CONSTRUCTION RECORD
� s
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: f. DISINFECTION:Type JC& Amount
g. WATER ZONES(depth):
Well Contractor(Individual Name From To From To
U Ef.-' e if l W,11 i t'a k 1 nC, From To From To
Well Contractor Company Name From To From To
STREET ADDRESS IA2 ?)tUL 9',dQ f' Piros) 6. CASING: Thickness/
^ Depth Diameter Weight Material
T(i o�tsv i U c Cj.4 �5 I Z From 0 To Ft. 4%/ -
City or Town State Zip Code From To Ft.
( 0 W ,_ -7y5- 21(pty From To Ft.
Area code- Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material Method
From 0 To a• Ft. O
SITE WELL ID#(d applicable) From 0 To o� Ft. M
STATE WELL PERMIT#(ff applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 0 -?-09149 a SCREEN: Depth From v� To _ Ft.C1 n. in.Diameter Slot Size Material
/k! . 20
WELL USE(Check Applicable Box): Residential Water Supply.' From To Ft. in. in.
DATE DRILLED CAA A02- 2I From To Ft. in. in.
TIME COMPLETED AM❑ PM❑
9. SAND/GRAVEL PACK:
3.WELL LOCATION: 1 Depth Size Material
CITY:
SV'l��G COUNTY From
n/a� To Ft —
I?5 OIc1 �t�►7V SAS{' V69 0 L4 From To Ft.
(Street Name,Numbers,C mmunity,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation escription
(check appropriate box)� minutes,seconds or - Ar a r�n� &/
LATITUDE May be in degrees, 4ris / q,S /�ifdlc� /,04r
—
LONGITUDE in a decimal format � a=R G r
Latitude/longitude source: ❑GPS ❑Topographic map
(location of we#must be shown on a USGS topo map and
attached to this form if not using GPS)
4.WELL OWNER r
OWNER'S NAME C-L U t e k -2nA 1(-1e.Z
STREET ADDRESS
City or Town State Zip Code
za )-910l-99210 Info roc
ussing
(
Area code- Phone number [)WR 5ecllull
11. REMARKS:
5.WELL DETAILS:
a. TOTAL DEPTH: IO�J
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO.W
G WATER LEVEL Below T Of Casing: �7 y� 11
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
Op g: LV FT. 15A NCAC 2C,W ELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
(Use"+"if Above Top of Casing) RECOR i S BEEN PROVIDED T THE W LL OWN
d. TOP OF CASING IS �•r FT.Above Land Surface.* �r
'Tap of casing terminated with below land surface may require ATURE OF CERTIFIED WELL CONTRACTOR '
a variance in accordance with 15A NCAC 2C.011_8.L
VATE
e. YIELD(gpm):O METHOD OF TEST rtti`1 '�"'v �'11`/Afi5l,
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt., Form GW-1a
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 668. Rev.7/05
w