GW1-2022-04837_Well Construction - GW1_20220520

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
27RO 220071
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: f. DISINFECTION:Type_HTH Amount 'ICJ
KPI i H PPESNELL g. WATER ZONES(depth):
Well Contractor(Individual Name) From 170 To 17z _ From 270 To113
From To From To
Well Contractor Company Name From To From To
STREET ADDRESS P. 0.BOX 308 6.CASING: Thickness/
E00111E ?taC 22607 Depth Diameter Weight Material
From 0 To 60 Ft. 61/9 .350 P V C
City or Town State Zip Code From To Ft.
( 2fS )=��551 From To Ft.
Area code-Phone number
7.GROUT: Depth Material Method
2.WELL INFORMATION:
From 0 To�.t7 Ftj31;"N'1'01-TI! Git avity 1i'I��u
SITE WELL ID#(if applicable) From To Ft.
STATE WELL PERMIT#of applicable) From To Ft.
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DWO or OTHER PERMIT#(f applicable) 'tti� _�•-c� 8.SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply Q From To Ft. in. in.
DATE DRILLED 5AS'20'.2 From To Ft. in. in.
TIME COMPLETED 03:VJ AM El PM M From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
CITY: L 5d-RI.RE KI COUNTY AV ERY
From To Ft.
-
From To Ft.
LOT G-3 9 LOTI)GES k T E:?GLF.S 1•7ES`T OFF SKY C.A.11,I
From _To Ft.
-
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box)
May be in degrees,
LATITUDE 3 minutes,seconds or t7.O t��6htITF
LONGITUDE in a decimal format i I i7,R _ c_H a LF PF=n
Latitude/longitude source: gGPS ❑Topographic map i?; �:,R t;P en.IITF
(location of well must be shown on a USGS topo map and 'P2 ^3n _ RIM rZPANITF
attached to this form if not using GPS) _7n11 27,E t'P A WITF
4.WELL OWNER �,i1-I '.)7) Vf�li7
OWNER'S NAMED LLG°L 17d )k SEF.ATP1 279 rPd-.NITF
STREET ADDRESS'/c T O?t�i ECJ ;C i6S T R_TTC i IC)J,I 9P-7 j H1,:- =�F'8 .n _ AF•O1, :�,M114 ,-
tdZ,=� ;-i- 1dC° ?:;::{(,d ;7n 6�� _ r�Le I ra _. (VCZ8-
City or Town State Zip Code Tp ,t "—
Area code-Phone number
5.W ELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH 42 5 7iT fy.rt�' ;rril� t7f'( L1� v ��y�l(;'j
U(,rr 1,70 17R 7 G-MIT �70_^7 3
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOO
c. WATER LEVEL Below Top of Casing: :;() FF. I DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
RECORD HAS BEEN RO, IDED T THE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface* � 1 v � �� /� z
'To of casingterminated at/or below land surface may require /
a variance in accordance with 15A NCAC 2C.0118 SIGNAT RE OF CERTIFIED 1NELL CONTRACTOR DATE
e. YIELD(gpm): 9' METHOD OF TEST Air 117I-r=' moo=•MINIM I
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days.Attn: Information Mgt., Form GW-1 a
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568. Rev.7/05

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