GW1-2022-04868_Well Construction - GW1_20220520

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 27,80 10221
1.WELL CONTRACTOR: f. DISINFECTION:Type
i H I H Amount 43
KEI T H FRE SELL g. WATER ZONES(depth):
Well Contractor(Individual Name) From 180 To 190 From 230 To 232
U Yt oAVH-.IGH T WELL as F'UfviF C0., 1f,IC C.
From To _ From To
Well Contractor Company Name From To _ From To
STREET ADDRESS 7 O•EOX 302 6.CASING: Thickness/
�O(-IT 11C 2�G07 Depth Diameter Weight Material
From Ci To 0 Ft. n`Ii'; iS(i PLr(11
City or Town State Zip Code From To R.
( 03 )-26-1-2 51 From To Ft.
Area code-Phone number
7.GROUT- Depth Material Method
2.WELLINFORMATION: From 0 To 20 Ft.EYNT NIT CrayitvF)am
SITE WELL ID#(if applicable) From To Ft. 118 BAGS
STATE WELL PERMIT#of applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) � � &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply 0 From To Ft. in. in.
DATE DRILLED 5/4l2022 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM® From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
_ Depth Size Material
CITY: COUNTY t ' From To Ft.
��_r CY a From _To Ft.-
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) j I 71� n I RT
May be in degrees, —
LATITUDE 3 ii,l;ti it+ minutes,seconds or 7n 1^-,n
LONGITUDE _til ;��r;+ 7 in a decimal format I8n 101] �'H 61
Latitude/longitude source: A GPS ❑Topographic map -3?I 1
(location of well must be shown on a USGS topo map and =:ry ^=L _ �SriIl
attached to this form if not using GPS) ,•�, ,�75 t;RPitIITE
4.WELL OWNER
OWNER'S NAME�Li-`T71 &L A1TIN!
STREET ADDRESSt� LI;��J�Y!`?T2"tTt_TlC1f! 7,74 I-'EN C
FANNER ELZ NC 286t
City or'7Town State Zip Code � - C
Area code-Phone number '`��w^ytr:�c, • � •,;.,.,.....
_ �r.`r{, �!�'iE'o.+�.;t.rt.;,i
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 305 2 GT)n$ 160- i90 18 r M,1 2.30-232.
b. DOES WELL REPLACE EXISTING WELL? YES❑ 1\10�7
c. WATER LEVEL Below Top of Casing: 1(k) Fr. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
RE ORD HAS BE UN P OVID O THE WELL OWNER.
FT Above Land Surface �j /7
d. TOP OF CASING IS 1 ` V- /
Top of casing terminated at/or below land surface may requireF AA
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF C -Rc�,
ED ERTIFI W L CONTRACTOR DATE
e. YIELD(gpm): 20 METHOD OF TEST Air I;FlT4 i PF2FgNIP 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-ia
1617 Mail Service Center-Raleigh, NC 27699-1617 Phone No. [phone] ext 568. Rev.7/05

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