GW1-2022-09809_Well Construction - GW1_20221027

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_ - RESIDENTIAL WEL
L CONSTRUCTION RECORD
North Carolina Departtnent of Environment and Natural Resources-Division of Water Quality
'WELL CONTRACTOR CERTMCATION# '==`
Fen
NTRACTOR:
`O;DAN f. DISINFECTION:Type H I L
ctor(Individual Name) —
Amount 39
to ( id _- 9• WATER ZONES(depth:
— 'tic PL:iviM 'ter? °�;r'= From �77 3t; , 9 Tq-- From T_0 Toctor Company Name From To-i.- From_ ToDRESS .0. -0_-K�Fx, From To From To
i 6.CASING:I_. -- Thickness/
Depth
City or Town State -- From _ To Diameter Weight Material
r R _
Zip Code Ft. a _ram--
( =: )=tom sc`=1 From To
Ft
Area code-Phone number From To Ft.
2-WELL INFORMATION: 7.GROUT- Depth Material
Method
SITE WELL ID applicable)#(f From 1 To ^(j
STATE WELL PERMIT#(rfappricable) From To
---- DWQ or OTHER PERMIT#(Capplicable)_i -L%•
D o_--i_sc____ From To Ft
WELL USE(Check Applicable Box): Residential Water Su 1y - 8-SCREEN: -Depth Diameter Slot Size Material
DATE DRILLED 9/;`� ;^.• Pp From To Ft. in. in.
TIME COMPLETED 03=O AM❑ PM•io From To Ft in. in.
From To Ft
in. in.
3.WELL LOCATION: S.SAND/GRAVEL PACK-
CITY-1 -:trlr—e-_a, N� Depth Size
COUNTY --+--•-- Material
From To Ft.
\4=C-P:r;_- L r r O L_F'�,ti�,I i SK-r_7_K From To Ft
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft.
TOPOGRAPHIC/LAND SETTING:
❑Slope El Valley ❑Flat ❑Ridge ❑Other 10.DRILLING LOG
(check appropriate box) From TO Formation Description
LATITUDE 3 MaY be in de�ees. °t Rr ti t i
— ��.LNG L�,T minutes.seconds or
LONGITUDE i�jr f 3ti in a decimal format Of i -_,?I%1!--=
Latitude/longitude source: Cn Q GPS ®Too l
Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4-WELL OWNER
:W)
OWNER'S NAM t=r _:: '-' =str+;Ta,�r;zr
STREET ADDRES$� = :
�:�
City or Town State Zip Code - O f T 2 d
Area code-Phone number '^
.., U
5.WELLDETAILS: ^~
a. TOTAL DEPTH: ±st U.REA_ S: _
b. DOES WELL REPLACE EXISTING WELL? YES ElNQ EE7
c. WATER LEVEL Below Top of p of C.Ping)) I4jPM F- I DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Else"+"if Above Top of Casing) �V CY 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THATA COPY OF THIS
d. TOP OF CASING IS i 'p RECORD HAS BEEN PROVIDED TO THE WELL OWNER
FT Above Land Surface' i%'����
Top of casing terminated at/or below land surface may require �C ���R
avariance in accordancewith'15ANCAC2C.0118 ^ C 2GNA0RFi ' DATE
e. YIELD(gpm): f� METHOD OF TEST r2:-
r:•ter i.r.r
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days.Attn:Information Mgt.,
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No. [phone] ext 568. Form GW-1a
Rev.7/05

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