382569_Well Construction - GW1_20100420

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 17:47
1 WELL CO TRACTOR'
Ijr g, c e difO ,
Well Contractor (Indrnduai) Name
l t /� Sr,.; tt.5 S
Wei( Contractor Company Name
//ate e
Street Address /
�f 5,04,<%/".-9
City or Tim J
() (P 4S - 2Q�
g WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight aterial
Top / Bottom
Yl Ci)�1 �/l�J 92 Top Bottom / Ft
State Zip Code
Top Bottom Ft
Area code Phone number 8 GROUT Depth Material Method
2 WELL INFORMATION Top 0 Bottom a Ft L�/ eRt iiQia�C
WELL CONSTRUCTION PERMIT# �(� J��G j ! �j Top Bottom Ft i
OTHER ASSOCIATED PERMIT#(rf applicable) Top Bottom Ft
SITE WELL ID #(d applicable) a /
3 WELL USE (Check Applicable Box);)Residential Water Supplygi
DATE DRILLED / -7/ /L'
l
TIME COMPLETED / � �f Aft] PM ❑
4 WELL LOCATION
CITY, ( ([d.( C't CJv0 COUNTY tci•c'Crtbe-,
Nl /.C1./u.nc`Y'1/4. I V 4v(/tt/,` r'i,t)/1
(Street Name Numbers, Community, Subdivision, Lot No , Parcel �Z!}I C
p Code) Top Bottom Ft
TOPOGRAPHIC / LAND SETTING (check appropnate box)
DSlopeValley DFlat DRidge ❑Other
LATITUDE 36 °?,} 'S4)%`l ,Y" DMS OR 3x XXXXXXXXx DD
LONGITUDE 75 '3/2 .) " DMS OR 7x XXXXXXXXX DD
9 SCREEN Depth Diameter Slot Size Material
Top Bottom Ft in in
Top Bottom Ft in in
Top Bottom Ft in in
Latitude/longitude source PS [Ropographic map
(location of well must be sho • on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER `
E fir - - Yidp,c
Owner Name �)
Street Address
/ i
City or Town State Zip Code
( zcX) ...1/6 - 0,M5
Area code Phone number
6 WELL DETAILS /��F a TOTAL DEPTH
b DOES WELL REPLACE EXISTING WELL', YES D NO
c WATER LEVEL Below Top of Casing (4V
(Use '+* if Above Top of Casing)
d TOP OF CASING IS ' FT Above Land Surface*
*Top of casing terminated at/or below land surface may require
a vanance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) t�` METHOD OF TEST K '
f DISINFECTION Type ti 01 S Amount
FT
10 SAND/GRAVEL PACK
Depth Size Material
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top/ Bottom
/
/
12 REMARKS
Formation Descnption
e E. BAR
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 WELL OWNER
SIGNATURE OF CEfTTIFIE[4'WELL ,ONTRACTOR
J ektki k k -.na
f PRINTED NAME OF PERSON C NSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - information Procesrir
1617 Mali Service Center, Raleigh, NC 27699-161, Phone • [phone]
FEB 2 5 2013
di0
DATE
Form GW-1a
Rev 2/09