386212_Well Construction - GW1_20100812

1 VJIELL CONTRACTOR
RESIDENTIAL WELL CONSTRUCTION RECORD
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North Carolina Department of Environment and Natural Resources- Division of Water Quality JAN 5 2O1 WELL CONTRACTOR CERTIFICATION # 2 E Co 3 212
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ell Contractor (Indmdual) Name
CQt eeA"1 ic—k4V *1-€SS
Well Contractor Company Name
Street Address
any-Ian°Q t �1c- 2P"7.B
City or Town State Zip Code
Ega 2'18-111-1
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT#
P i d
OTHER ASSOCIATED PERMIT#(it applicable) 16i—
SITE WELL ID #(if applicable) . `/ k
3 WELL USE (Check Applicable Box) Residential Water Supply ( s
DATE DRILLED
1
TIME COMPLETED 3 - 3a AM 0 PM'.
4 WELL LOCATION
CITY WOC)d 1l COUNTYrgVlnCIr(1b
�H C3ar 10\ Vic(
(Street Name, Numbers, Community, Subdivision Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
O Slope [Valley p Flat
LATITUDE "
LONGITUDE
❑Ridge ❑Other
" DMS OR 3x xxxxxxxxx DD
" DMS OR 7x xxxxxxxxx DD
Latitude/longitude source PS ❑topographic map
(locabon of well must be s own on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
1VA�� HH'-ckctck.
Owner Name
Street Address
, 1\1 c-
ty or Town State Zip Code
Area code Phone number
6. WELL DETAILS -
a. TOTAL DEPTH
yos
b DOES WELL REPLACE EXISTING WELL? YES 0 NO 0
c WATER LEVEL Below Top of Casing G% 0 FT
(Use "+" if Above Top of Casing)
d TOP OF CASING IS ii Above Land Surface'
*Top of casing terminate at/or below land surface may require
a vanance in accordance with 15A NCAC 2C-1 0118�
e. YIELD (gpm) METHOD OF TEST=t1 riled
f. DISINFECTION- Type t C., i14- Amount /007_
g WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING- Depth Diameter Weight Matenal
Top �rn
Bottom Ft CPA c 6)1 A`---
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Matenal Method
Top Bottom Ft i1 Sc. re nei
Top Bottom Ft Chips
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
Ft
Slot Size Material
in
in
in
e Matenal
Formation Descnption
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i U n 2 2010
In
on pr
Q/8
9 Unit
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
PR'� O THE WELL O N�
l27./ , l0
SIGNATOF CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
-- F_ -1 Fit 7_3�,r rn ;_-�j. _mo d_.,._,. -._- .,,-T.^zti
Subimitxwithin 30-days: of completion to: Division of Water Duality -- Infarmatlon Pt`acessi
1617 Mail 3er'viceCenter, Raleigh,*C 27699-161, Phone c.(9191807-300 y :
Form GW-la
Rev 2/09