384046_Well Construction - GW1_20100323

Latitude/longitude source S Qropographic map
(location of well must be s°h°wn n a USGS topo map andattached to
this form rf not using GPS)
5 WELL OWNER
-RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
State Zip Code
Street Address /
City or 1r �� ��/f
tY / own
(___) State Zip Code
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH ()_5
b DOES WELL REPLACE EXISTINGWELL'? ELL? YES ❑ NO
c WATER LEVEL Below Top of Casing 1 /; >/
(Use "+" if Above Top of Casing) FT
d TOP OF CASING IS
*Top of casing terminated at/or below landFT Above Land Surface*
a variance in accordance with 15A NCAC 2C 0118 require
e YIELD (9Pm)
METHOD OF TEST � f DISINFECTION Type iaS_ ���_,_
Amount
Submit Within 30 days of completion to. Division of Water Q
1617 Mail Service Center, Raleigh, NC 27699-161, Phone (919) 80
I WELL CO-yTRACTOR
Well Contractor (Individual) Name
. 9 1
Well Cbnttractor Company tame
Crfir or Town
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�f
DATE DRILLED f / j- U /r
TIME COMPLETED 3(,
AM 4 WELL LOCATION PM
/
CITY ( /it.q/r'1--
COUNTY ,V7('(-97L
(Street Name Numbe Co
% //ctX
mmunity Sidivis yn Lot No Pararcel Zip
iTOPOGRAP IC / LAND SETTING (check appropnate box)
[]Slope alley ❑Flat
❑Ridge ❑Other
LATITUDE 36 ^ / ^
LONGITUDE 75 i ? DMS OR 3x XXXXXXxxx DD
n
ISMS OR 7x XX�XXXX DD
ode)
9
Top
Top
Top_
Top
Top.
Top
Top Bottom
Top Bottom
Top Bottom
7 CASING Depth
Diameter Weight Material
Top 'a" Bottom � � Ft _Iv_� 7,,C*17
Top Bottom/ Ft % l%�o r
Top Bottom � �/� l
Ft
WATER ZONES (depth)
Bottom
Bottom
Bottom
8 GROUTDDepth
Top ti Bottom
Top Bottom_
Top Bottom
9 SCREEN Depth
Bottom_
Bottom_
Bottom
10 SAND/GRAVEL PACK
Depth
Top Bottom
Top Bottom
Top Bottom
11 DRILLING LOG
Top Bottom
/
/
/
12 REMARKS
Material
Ft L`%_ fh2 i
Ft
-----------
Ft
Diameter Slot Size
Ft in
Ft inin
Ft in
In
Ft
Ft
Ft
Size Size Material
Formation Descnp n
A
Method
Material
Intoirriaflon P7OC-9b+ii+� v: r
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
PROVIDETOTHE WELL OWNER
SIGNATURE OF CERTIFIED WELL CON AC `�� f C%
�,`' `/ �//`a- T/ /` R DATE
�
PRINTED NAME OF PERSON CONSTRUCTING THE 7 L ti,r r /y,c
uality - information Processing
MS
7-6300
Form GW-1a
JAN 1 8 2013 Rev 2/09