382568_Well Construction - GW1_20100420

RESIDENTIAL WELL CONSTRUCTION RECORD
North Caroi,na Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1 WELL. C9NTRA/�C/TOR-
well Contractor (Individual) Name
G/25
Wen Cont
2ctor Company Naame
Street Address
-,Zifi
City or Td'wn d
L ()
Area code
Phone number
2 WELL INFORMATION:
WELL CONSTRUCTION PERMIT# C)/G) - >
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(rf applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply
DATE DRILLED
TIME COMPLETED
4 WELL LOC TION-
CITY GliaL4AL
State
Zip Code
Aezd
AM 0
COUNTY
PM
a4t•Top
g WATER ZONES (depth)
Top Bottom Top
Top Bottom Top
Top Bottom Top
3 ( �?� P t'
Bottom
Bottom
Bottom
7 CASING Depth Thickness/
� /� Weight Matenal
Top Bottom 4 Ft 41 e-
Top Bottom Ft —L�_
Top Bottom Ft
8 GROUT Depth Matenal
Top 0 BottomL Ft ee/i eit t
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft in in
10 SAND/GRAVEL PACK
Method
9 SCREEN Depth Diameter Slot Sire
Material
Top Bottom Ft in in
Top Bottom Ft in
in
.lier/24_
Depth Size Matenal
Bottom Ft
Top Bottom Ft
nrty, Subdivision Lot No , Parcel Zip Code)
*alley
Top
❑ SI gg Vope alley p Fiat O Ridge ❑ Other
LATITUDE 367.1„C' sif c'�,�.+, DMS OR 3X XXXXXxXXX DO
LONGITUDE 75 e . 73�J,']�
�!— LAMS OR 7X XX =xXX DD
Latitude/1origrtude source 3lC;PS
(location of we/I must be sho�opographrc map
this form rfnot using GPS) on a USGS topo map andattached to
5 WELL OWNER
(5t -et Name mbers, Com
TOPOGRAPHIC / LAND SETTING (check appropnate box)
Ow
rName
l
tr:et Ad. -ss
ity or Town
State Zip Code
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH
b DOES WELL REPLACE EXISTING WELL? YES 0 NO
c WATER LEVEL Below Top of Casing
(Use °+^ if Above Top of Casing)
d TOP OF CASING IS_ FT Above Land 'Top of casrng terminated at/or below land surface mayrrequi
a vanance rn accordance with 15A NCAC 2C 0118 y. feurre
e YIELD (gpm) h METHOD OF TEST !%(___
f DISINFECTION Typepe=—�,f�—'--
t Amount PR
Submit within 30 days of completion to: Division of Water Quality TED NAMEOFPERSON NSTRUCTING THE WELL
1617 Mail -Service Center, Raleigh, NC 27699-161, Phone [phone]
n Processing, TM
FT
11 DRILLING LOG
To$ 132:
12 REMARKS
Bottom Ft
Diameter
Formation Descnphon
ave4
i
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
PROVIDED TO THE ELL OWNER
-1
SIGNATURE OF CE
DATE
Form GW-la
Rev 2/09
FEB 25Z013