GW1-2021-04358_Well Construction - GW1_20210429

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RESIDENTIAL WELL CONSTRUCTION RECORD
w ` North Carolina Department of Envi nt and Natural Resources-Division of Water Quality
WELL CONTRACTOR IIO1t ATIO # C
1.WELL C TRAC OR: �� 5`'� g. WATER ZONES(depth):
ry VP'-19", Top IZO Bottom Top Bottom ptloo
ell Contractor(Individual)Name
� �j� Q c�� TOP Bottom . Top_Bottom
L ( of� I.V�>XJ� _t161P-�R- Top Bottom Top Bottom
Well Contghcfor Company Name
II �� � \r r Thickness/
�(1 inp. c ; 7. CASING: Depth Diameter Weight Material
Street�4ddress N Top GL Bottom Ft. _
!/ Z7/ Top Bottom Ft.
City or Town State Zip Code Top Bottom Ft.
Area code Phone number 8. GROUT: Depth i Material Method
2.WELL INFORMATION: Top GL Bottom-1-OL Ft.
WELL CONSTRUCTION PERMIT# Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft.
SITE WELL ID#(if applicable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply❑ Top 161,6 Bottom 0 Ft. in. in. 10y G
DATE DRILLED f04J �d'2 ; Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
TIME COMPLETED AM❑ PM❑
4.WELL LOCATI 10.SANDIGRAVEL PACK:
CITY: COUNTY Depth 1ze �M+ate ai
Top l,�J Bottom /g� Ft. J_
Top Bottom Ft.
(Street Name,Numbers.Community,Subdivision,Lot No.,Parcel,Zip Code) Top Bottom Ft.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope alley ❑Flat ❑Ridge ❑Other 11. DRILLING LOG
LATITUDE 36 � Top Bottom Formation Description
"DMS OR 3X.XXXXXXXXX DD /
LONGITUDE 75 "DMS OR 7X,XXXXXXXXX DO
LatitudeAongitude source: (BPS Qropographic map /
(location of well must be shown on a USGS topo map andattached to l
this form if not using GPS) l
S.WELL OWNER - /
wner Name
Street Add s /
ty r Town S State Zip Code /
c ,,q-A 6 Z 6
Area code Phone number 12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH: U
b. DOES WELL REPLACE EXISTING WELL? YES❑ NM
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+"If Above TQp of Casing) STANDARDS,AND THAT:A COPY OF THIS RECORD HAS BEEN
I/ PROVIDED TO THE WELL OWNER.
d. TOPSurface* D t/
*Top
CASING IS FT.Above Land of casing terminated at/or below land surface may require
z !ore J-7 d- r'
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): or METHOD OF TEST 9" L �C�
Mr- 9
/ ,
� g �+ ,1-._D l` �� A,,f. DISINFECTION:Type Tt r- 9 Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to:Division of Water Quality- Information Processing, Form GWAa
1617 Mail Service Center,Raleigh,NC 27699-161,Phone:[phone] Rev.2/09