381912_Well Construction - GW1_20100323

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1 WELL CONTRACTOR
t (ell Contractor (Individual) Name
S
Well Contractor Company lame
1 y S it e R-1 ,
Street Addrep
; e� � n e ` .2 ,1 J
( Crtyor)Town State Zip Code
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply 0
DATE DRILLED 'c8. ao to
TIME COMPLETED
4 WELL LOCATION
CITY r ./t11,(t;QJF.f COUNTYFie e Moe Ivt
(Street Name Numbers, Community, Subdivision Lot No Parcel
Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
oSlope ❑Valley ❑Flat ORidge ❑Other
LATITUDE 36 ° 3 7 ' 7C59t " DMS OR 3x XXXXXXXXX DD
LONGITUDE 75 ° 6)e13 " DMS OR 7X XXXXXXXXX DD
Latitude/longitude source S Dfopographic map
(location of well must be own n a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
Grex ;.eci
Owner Name
COE Fie/Cite( *C4.074, n Roil
Street Address
klekgeler
City or Town State Zip Code
AM ❑ PM
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH ti1).
b DOES WELL REPLACE EXISTING WELL? YES 0 NO
c WATER LEVEL Below Top of Casing / tj C FT
(Use "+" if Above Top of Casing)
FT Above Land ace*
"Top of casing terminated at/or below land surface mayrrequire
a vanance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) g
f DISINFECTION Type Amount 20
d TOP OF CASING IS
METHOD OF TEST
a-/
3 2
u Lei
g WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top"' I Bottom 4t Ft 4 4 1,:2! ri" 4,.-
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth �,
Top 0 Bottom Ft
Top Bottom Ft
Top Bottom Ft
Material
Method
"-V)(1-
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 Bottom
( / 605
/
/
/
/
12 REMARKS
Material
Formation Descnppein
e v,141
e.8,*
Q " ,
\
\r
VP
1.7
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDA AND THAT A COPY OF THIS RECOHAS BEEN
PROVIDI= TO THE WELL OWNER
N.
SIGNATURE OF CERTIFIED WELL CON AC R/ DA
TE
D AE
PRINTED NAME OF PERSON CONSTRU, ITING THE WELL
Submit within 30 days of completion to Division of Water Quality - Informatron Processing,TMS
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
Form GW-la
Rev 2/09
FEB 2 5 ZU13