382572_Well Construction - GW1_20100420

1 WELL COBTRACTOR
Well Contractor (1 dividual) Nam
e
Well C)ntractor Company lame
Street Address �/
%7 Ft 1,_j 04
ti p ; tt a(4 u f)
Gip or Town i State Zip Code Ft
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT#
9
Top Top Bottom
Top Bottom Top Bottom
i Top Bottom Top Bottom
I n e 11-W / f Thickness/
Diameter Weight
OTHER ASSOCIATED PERMIT#(if appicable)
SITE WELL ID #(if applicable)
- '1
3 WELL USE (Check Applicable Box) Residential Water Supply
DATE DRILLED ,'i '‘72,i — i 0 /
TIME COMPLETED 3 c AM 0 PM ('7
4 WELL LOCATION O
r k 'L
CITY RV tv,V V . \ (-_ COUNTY 3 f,✓`v_ c h,,io +;,..
rt,
(Street ame Numbers, Communrty, Sbdivision Lot No Parcel Zip Code) •
TOPOGRAP IC / LAND SETTING '(check appropnate box)
❑Slope Valley DFlat ❑Ridge ❑Other
LATITUDE 36 °j ' ?SNCI'1 °DMS OR 3x XXXXXXXXX DD
LONGITUDE 75 ° • Sii' C
Latitude/longitude source �.
(location of well must be own
this form if not using GPS)
5 WELL OWNER
Owner Name
DMS OR 7x XXXXXXXXX DD
S ['Topographic map
n a USGS topo map andattached to
C td CL2y /t 41,u0
3lc, it Pe, I otA_ 1jrvit C--
Stet Address 1
City or Town
021) I
Area code Phone number
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality ej
WELL CONTRACTOR CERTIFICATION #
¢ 0_
6 WELL DETAILS
a TOTAL DEPTH YG.I -5
c WATER LEVEL Below Top of Casing
(Use "+" if Above Top of Casing)
State
Zip Code
b DOES WELL REPLACE EXISTING WELL? YES 0 NO
tf i)
d TOP OF CASING IS
*Top of casing terminated at/or below land surface may require
a vanance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) METHOD OF TEST .6r
f DISINFECTION Type t't , 'c Amount
FT
FT Above Land Surface*
-R
WATER ZONES (depth)
Bottom
7 CASING Depth
Top1 f Bottom
Top Bottom
Top Bottom Ft
8 GROUT Depth
Top 0 Bottom Ft
Top Bottom Ft
Top Bottom Ft
Material
is: coked"
Material
Method
qs)eL,efi
9 SCREEN Depth Diameter Slot Size Material
Top Bottom Ft in in
Top Bottom Ft in in
Top Bottom Ft in in
10 SAND/GRAVEL PACK
Depth Size
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bo
/
/
/
/
/
/
/
12 REMARKS
Material
Formation Descnp}tign L� yr
L, e L 13 1!- %r� (J
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDA- r., AND THAT A COPY OF THIS RECO HAS BEEN
PROVIDE. TO THE WELL OWNER
SI NATURE OF CERTIFIED WELL CON SAC i� ' ,Y DATE
i
PRINTED NAME OF PERSON CONSTRUC N TRrIE:W l5J
f.
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
Form GW-1a
Rev 2/09