387456_Well Construction - GW1_20100101

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1 WELL CONTRACTOR
Chad tSk-C.4t
Well Contractor (Individual) Name
AWD Services Inc
Well Contractor Company Name
258 North Turkey Crk Rd
Street Address
Leicester NC 28748
City or Town
( 828) 683-9223
Area code Phone number
2 WELL INFORMATION ��77 q
WELL CONSTRUCTION PERMIT# OtO 1 `d 31 Q1
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply d
DATE DRILLED 3/ II 1 l
TIME COMPLETED AM ❑ PM ❑
4 WELL LOCATIQN
CITY W445/CAM) tx COUNTYZiANC(iNte
(R W� 11� 1"15we r PI470 .-7rP: L
age15
(Street Name Numbers Community Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑Slope ❑ Valley ❑ Flat ❑ Ridge ❑Other
LATITUDE 35 " DMS OR 3x XXXXXXXXX DD
LONGITUDE 83 " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source [ PS propographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
Sa5D� t- 6w-a 1\11;i4nat(
Owner Name
6,9 (,J.‘ 114-toTdi
Street Address
oA n a 1P/V 1Q C- 7f g
City or`Town State Zip Code
Area code Phone number
6 WELL DETAILS rj 1
a TOTAL DEPTH 7 ./
b DOES WELL REPLACE EXISTING WELL? YES CINO VA
c WATER LEVEL Below Top of Casing 300 FT
(Use '+" if Above Top of Casing)
d TOP OF CASING IS I FT Above Land Surface*
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C0y�11_,11'8NN��, __
e YIELD (gpm) 1. METHOD OF TEST�n.c t t
f DISINFECTION Type ) of (tg�1Amount A
Top
Top
Top
7 CASING
Top—G'
Top
Top
,35vo
g WATER ZONES (depth)
Top —C�• Bottom LeoQ Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
Depth Diameter a �Weight Material
Bottom ep Ttt FtCQ k " 5&1u PVC
Bottom Ft
Bottom Ft
8 GROUT Depth Material �, Method
Top 'Q Bottom � ( Ft w ,tJC.. rPC)-A.).,1(
Top Bottom Ft
Top Bottom Ft
9 SCREEN Depth
Top Bottom
Top Bottom
Top Bottom
10 SAND/GRAVEL PACK
Depth
Bottom
Bottom
Bottom
11 DRILLING LOG
Top Bottom
/
/
12 REMARKS
Diameter Slot Size Material
Ft m in
Ft in in
Ft in in
Ft
Ft
Ft
Size Material
Formation Description
SEP 1 4 2010
Informauoii '
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER
as
/0
SIGNATURE OF CERTIFIED WELL CONTRACTOR IATE
PRINTED NAME OF PER ON CONSTRUCTING
RUCTINGG THE WELL
Submit within 30 days of completion to Division of Water Quality -, Information Processing, MS Form GW-la
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone] JAN 07 2013 Rev 2/09