382570_Well Construction - GW1_20100101

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # o244,c1
1 WELL CONTRACTOR
K:e.30n Ltlt u,Xtie.
Well Contractor (Individual) Nam
G\ycie So.,.. ec5 41 Soh te\t h--?, ,,w.a
Well-eontractor Coii ny Name l
STREET ADDRESS \L'►AS 5 1-\.•, aoci
t\o-k 5 c;vt,<IAC a irP-13
City or T state
( Bag )- 4475- 02 4y0
-Zip Code
G-� j
Area code- Phone number
2 WELL INFORMATION ��J
SITE WELL ID #(if applicable) —'!-",
STATE WELL PERMIT#(if applicable)
DWQ DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Residential
DATE DRILLED ! �` —(
r
Water Supply
0 PM4(
`` �(
bv.-'i't,t C r;,h,
TIME COMPLETED 3 & C AM
3 WELL LOCATION
CITY O'-'fit I\ COUNTY
n p {
r ( 4._ -1) e,} ifs ,� , yr (2---'(Street
Name N ambers Corn unity Suodirisian, Lot No Parcel Zp Coder
TOPOGRAPHIC / LAND SETTING
ASlope ❑ Valley ❑ Flat ❑ Ridge ❑ Other
(check appropnate box)
i t r
LATITUDE 3 _5- tf, I 1 `f l i I
May be to degrees,
minutes, seconds or
in a decimal format
LONGITUDE 7 Y,; ?y/
Latitude/longitude source PS ❑Topographic map
(location of well must be sh n on a USGS topo map and
attached to this form d not using GPS)
4 WELL OWNER
OWNER S NAME i3 (-� J O e L✓ —2_,
i
STREET ADDRESSF I—'),1 X;-,N,i? TIC..
'f1
ryC'
f--,, �1, itic 1 1�1
City or own State
( )-
Zip Code
/
YES 0 NO Q'
ii, FT
Area code - Phone number
5 WELL DETAILS ;
(2
a. TOTAL DEPTH -' /j
b DOES WELL REPLACE EXISTING WELL'S
c WATER LEVEL Below Top of Casing
(Use "+" if Above Top of Casing)
d TOP OF CASING IS I FT Above
Land Surface*
may require
2C 0118
R* q
*Top of casing terminated at/or below land surface
a vanance m accordance with 15A NCAC
e YIELD (gpm) .._,-'r/ METHOD OF TEST
f DISINFECTION Type'; I S
g WATER ZONES (depth)
From To From To
From To From To
From To From To
9 ,no {.
cn +tr
Amount
6 CASING Thickness/
Depth -� Diameter Weight Material
From -I-\ To '3✓ Ft (6 IA -,h,Q\ ? VC
From To Ft
From To Ft
7 GROUT Depth Material Method
From 0 To o1O Ft Ceti ytt 'OI.1.Ce.8..
From To Ft
From To Ft
8 SCREEN Depth Diameter Sht Size Material
From To Ft in _ in
From To Ft in in
From To Ft in in
9 SAND/GRAVEL PACK
Depth Size Matenal
From To Ft
From To Ft
From To Ft
10 DRILLING LOG
From To
11. REMARKS:
Formatioi Descnptio{t
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRICTED IN ACCORDANCE WITH
15A NCAC 2C WELL CONSTRUCTION STANDARDS ANC) THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF Cali IFIED WELL CONTRACTOR DATE
i`i:e+h l.a}cam\;?
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-la
FED 295vZ813