387458_Well Construction - GW1_20100101

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of hnvironment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3� (
1 WELL CONTRACTOR
Coil. �o 5C
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
WELL CONSTRUCTION PERMIT# 020 0 1Q - 00 11!
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply IV
DATE DRILLED (3/ Cad / O
TIME COMPLETED AM 0 PM 0
4 WELL LOCATION (��( r'` ((����
CITYy` niet4V 1✓tl v 11 QJ COUNT' SJLtt'\'� 60
I i 1 PTY`('I KA OYI� St,Ve'(UI I 1.Q 3-$`+
(Street Name Numbers Community Subvvis�iioon I,pt o Ircel, Zip Code)
• OGRAPHIC / LAND SETTING (check appplropriate box)
TOTope [Walley ❑ Flat r� ❑Ridge ❑ Other
LATITUDE 35 °4�3' S61.41" DMS OR 3x XXXXXXXXX DD
LONGITUDE 82, ° u(p' Ot 3 W " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source ZIPS OTopographlc map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
LtSkr410tA5E, CPtroL, f10
Owner Name
Street Address
JeAv-ev-61le 0. o28�`bi-
City or Town
( )
Area code Phone number
6 WELL DETAILS �� �(
a TOTAL DEPTH
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO d
c WATER LEVEL Below Top of Casing I U v
(Use "+" if Above Top of Casing)
d TOP OF CASING IS 1 FT Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C0118(��
e YIELD (gpm) 5 METHOD OF TEST((`�D`t' w146, t
f DISINFECTION Type -31U Amount
FT
g WATER ZONES (depth)
Top Bottom
Top Bottom
Top Bottom
Top Bottom 3 s
Top Bottom
Top Bottom
7 CASING Depth Diaynpter
Top`G Bottom ��p (� Ft ��T u
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth
Top 0 Bottom2 1 Ft
Thickness/
Wei. ht
Material
f1 tenal --ra-�
V::)�1 /Method
Top Bottom Ft
Top Bottom Ft
9 SCREEN Depth
Top Bottom
Top Bottom
Top Bottom
10 SAND/GRAVEL PACK
Depth
Top Bottom
Top Bottom
Top Bottom
11 DRILLING LOG
Top Bottom
/
/
/
/
12 REMARKS
Diameter Slot Size Material
Ft m in
Ft in in
Ft in
Ft
Ft
Ft
Size
Material
Formation Description
SEP 1 4 2U1U
(nformaoc'
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
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
PRINTED 0 PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to Division of Water Quality - If sr atton'Processmg,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone] JAN U 7 2013
/0
Form GW-la
Rev 2/09