381419_Well Construction - GW1_20100302

I OPOGRAPHIC / LAND SETTING
itS1opP ri Valley Cl Flat f] Ridq
LA TITUDE if"35^'boa
LONGITUDE �v�^g c=1--
I atitude/longitude source SUPS
(location of well must be shown on a
this form if not using GPS)
5 WELL, OWNER
Owner Na e
Sheet Address
City or 1 own
State Zip Code
(cherk appropriate box)
e I /Other
DMS OR 3X XXXXXXXXX DO
5' DMS OR 7X XXXXXXXXX DD
f jfopographic map
USGS topo reap andettectted 10
Area rode Phone number
s WELL DETAILS.
a TOTAL DEPTH._
(#tit§et Name, Numbers Co mmunity, Subdivision Lot No
l2i c
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department nt Fnvironment and Natural Resources- Division of Watei Quality
WELL CONTRACTOR CERTIFICATION # 3500
1, WELL C • NTRACTOR
Welt Contractor (Individual) Name
5v►cl;5
Well Contractor Com any Name
Street Addre s
ni IC
City or Town
() ��3 9a State Zlp Code
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(If applicable)
SITE WELL ID #(dappiicabie)
3 WELL USE (Check Applicable Box) Residential Water Supply IN
DATE DRIL I_ED _ aka a TIME COMPLETED 101_
-------- AMC) PM 0
4 WELL LOCATION
CITY VV i iZV I EW COUNTY Gr �tOMl
r
A069- 60535
U.shCrt.
e ley , $ ode)
h DOES WELL REPLACE EXISTING WELL? YES I 1 NO V
WATER LEVEL Below Top of Casing
0 W TER ZONES (depth)
Top_ Bottom_14_0_ Top
Top __ Bottom Top
Top Bottom__ Top
7 CASING' Depth Dlame$er
Wei ht Material
Tope Bottom_ 4_6_ Ft _ _PVC
TopBottom_ rt
Top __ Bottom--___ Ft
Bottom
Bottom ^—�--�-
Botiom_`
Thickness/
8 GRRJT Depth r, Material
Top Bottom Method
Top Bottom Ft
Top Bottom
9 SCREEN Depth Diameter Slot Size
Top Bottom Material
itl In
Top Bottom`__ Ft _In
Top Bottom Ft m
10. SAND/GRAVEL PACK.
Depth Size
Top Bottom `_ Ft
Top _Bottom __ Ft V `
Top Bottom Ft
11 DRILLING LOG
Top Bottom
/
12 REMARKS
p
Materiel
Formation Description
iYSE it
\IVA� Gt' '1 Proc
Inroi
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
n f i
11iJy'
ATE
PRINTED NAME OF PERS N CONSTRUCTING THE WELI_
llbt11it within 30 days of Completion to: Envision of Water Quality Ihformtttion PrbceseIng,
i 7 Mail Service Center, Raleigh, NC 27699.161, Phone : [phone]
(Use "+" rf Above lop nt Casing) FT
d TOP OF CASING IS I F
e*
*Top of casing terminated at/or balowlland surfaceAbove d may require
a variance In accordance with 15A NCAC 2C 0118``
e. YIELD (gpm) ----T L__ METHOD OF TES6O I. C0friClinek,
f, DISINFECTION' Typo kii
Amount �-
Form GW-la
Rev 2/09