380033_Well Construction - GW1_20100104

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2S
1 WELL CONTRACTOR.
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ell Contractor (Individual) Name
SW-Cle4-War �Se9P
Well Contractor Company Name
Street Address
\i.larNr,cAno Q
City or Town State Zip Code
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Area code Phone number
2 WELL INFORMATION ��/�J
WELL CONSTRUCTION PERMIT# J-DD (/ -D(X3�fJ 1
OTHER ASSOCIATED PERMIT#(d applicable) HI
A -
SITE WELL ID #(r applicable) N/ k
3. WELL USE (Check Applicable Box) Residential Water Supply bk.
DATE DRILLED /J/a-7/oq
TIME COMPLETED (g. o(b AM ❑ PM (X
4. WELL LOCATION.
CITY elNaniajar1C0 COUNTY ntrillne
P l�Community, U
(Street Name umbers Subdmsion Lot No Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope ❑Va Ie u; lat ❑Ridge ❑Other
LATITUDE ° �e'' " DMS OR 3x xxx0000txx DD
LONGITUDE 3/° Z; ` 75 DMS OR 7x )OOOOOOOCX DD
Latitude/longitude source PS Dropographic map
(location of well must be s wn on a USGS topo map andattached to
this fomt tf not using GPS)
5 WELL OWNER
r-�barr-
OwnCar-e. ame
( (
Street Address
Pun -kcal- , N.L.
City ()gown
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Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH
75`7
State Zip Code
b DOES WELL REPLACE EXISTING WELLS YES 0 NO tT
c WATER LEVEL Below Top of Casing /4D FT
(Use "+" tf Above Top of Casing)
d TOP OF CASING ISC Above Land Surface'
'Top of casing terminate at/or below land surface may require
a vanance in accordance with 15A NCAC 2C-y01-1.8
e. YIELD (gpm) t g METHOD OF TEST { t lined
f DISINFECTION Type CC f-/- Amount /007_
Submttwithin 30rdays of.compietion to: -Division of, Water'Quahty'-; Information Processing;
,1617Mad Service �Center,Rdtleigh,-I4C 27699-16-1, Phone = (919)"807;6300 ; x F
_n �= - �� �_i .. .- - _... i.=.. .. _-Y _'( .. .... ... �uy� ✓ _.. __ . �� a. _ .tea
61) 0 r„
fv
g. WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight �++11, Matenal
T�L
Top Bottom 60 Ft (Se/f• �!
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Matenal Method
Top CJ Bottom O Ft_eibncrele. V1 p'H' f lt)(
Top Bottom Ft
Top Bottom Ft
9. SCREEN Depth Dtamete • Slot Size Matenal
Top Bottom in in
Top Bottom Ft m in
Top Bottom m
10 SAND/GRAVEL PACK.
Depth
Top Bottom
Top Bottom
Top Bottom Ft
11 DRILLING LOG
Top Bottom
/
/
/
/
/
/
/
12 REMARKS
Material
Formabon Descnpbon
Iteetia
.,ANU42010
Information Prr escing Unit
DWQ/BOG
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
PROED TO TH WELL OWN
SIGNATURE OF CERTIFIED WELL CONTRACTOR
et/,7 , vci 4,
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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9
ATE
GW-1 a
FEB 13 z '2/0s