386824_Well Construction - GW1_20100101

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1 LL CONTRACTOR.
1tr - bbi-H-
ell Contractor (Individual) Name
�e -yjlt k,v WeS..0
Well Contractor Company Name
na__CDICLS-rThS PDY12d
Street Address
GWany-Ianoq
City or Town
(PsLc3) 7 A S— t t l,
Area code Phone number
2P-1-78
State Zip Code
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# W E- L. 2c;09—cJ (c(ip
OTHER ASSOCIATED PERMIT#(d applicable) tislik
SITE WELL ID#(inapplicable)
3 WELL USE (Check
Applicable Box) Residential Water Supply Ili%
DATE DRILLED a." Z1 I 0
TIME COMPLETED Jam: to AM Q PM .
4 WELL LOCATION
CITY W ittveY vt it._- COUNTY �Q,
�
tics , c C 24-
(Street Name, Numbers Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (cheek appropriate box)
DSlope DValley oFlat ['Ridge pOther
LATITUDE " DMS OR 3x XXXXXXXXX DD
LONGITUDE " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source PS ['Topographic map
(location of well must be s own on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
-DOV t S YcU k-
Owner Name
I Bco
Street
Address
# Ur( \/l1
City or Town State Zip Code
(8z8) S 9s9 (:matt - Zaat
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 12S i
2
N<- 2BTsc5s
b DOES WELL REPLACE EXISTING WELL? YES CI NO
c WATER LEVEL Below Top of Casing 30 FT
(Use "+" if Above Top of Casing)
a
d TOP OF CASING IS t ieP Above Land Surface'
`Top of casing terminate at/or below land surface may require
a vanance in accordance with 15A NCAC 2C �t i 0118-�
e. YIELD (gpm) J METHOD OF TEST YYn.d
f DISINFECTION. Type (6 /4- Amount /007
3 6824
g. WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING. Depth Diameter CrnWeight A/C -
Top Top (./ Bottom S0 Ft SL A/ -
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Matenal Method
Tore). Bottom Ft 1 S d
Top Bottom Ft al I
Top Bottom Ft
9 SCREEN Depth Diamete
Top Bottom
Top Bottom
Top Bottom
10 SAND/GRAVEL PACK
Depth
Top Bottom
Top Bottom
Top Bottom Ft
11 DRILLING LOG
Top Bottom
12 REMARKS
Slot Size Material
m
in
in
Formation Description
SEP 0 2 2010
Information Processing Unit
D WO/60G
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
PRO ED
TO TH WELL 0 N
SIGNATOF CERTIFIED WELL CONTRACTOR
830— to
DATE
4 14r' L
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days-of,completion to: Division of Water`luality -lnformatlorn Processing,;;
1617 Mall Service Cetiter,,Raleigh, NC 27699-161, Phoney_(919)"807-63003- _„
Fo r,:�p
Rev 2/r ' V
JAN 0 7 2013