382611_Well Construction - GW1_20100420

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RESIDENTIAL WELL CONS rRRuCrION RECORD
Notth l arolina Department of 1 nvrronntunt and Natural IZu uutut_`,- Dry rtiron of \ atrr Ou.tlrty
WELL CONTRACTOR CER 111 ICA 1 ION r, \'CWC 2839-4
g WATER ZONES (d�pzrn)
1 WELL CONTRACTOR Top ij Bottom 7 Top
Brian Llllev Top Bottom Top
Well Contractor (Indrvidual) Name Top
Aaua Drill Inc Top Bottom Thickness/
Well Contractor Company Name
7 CASING Depth Diameter Weight Material
4137 Moores MITI Road Top 0 Bottom 75 Ft -tom Pic...
Ft
Ft
Bottom
Bottom
Bottom -
Street Address
Spencer
City or Toxin
336_) 767-0747
--yea code Phone number
2 WELL INFORMATION � ��G7� I��
'NELL CON S' RUCTION PERMIT V-
OTHER ASSOCIATED PERMIT #(d applicable)
SITE WELL ID 40h upprcaoie)
3 WELL USE (Check Applicable Box) Residential Water Supply 1-,/
D„ i E uRIL_Eo 4-5-
IME COMPLE TEE_ I Z :00
4 WELL LOCATION
i r, e_-1� l7n, A, J
VA 24165
State Zip Coae
4a Gl,tA
,Street Name Nurnoers Cornmunip Subeivrsion Lot No Parcel Zip Coae)
TOPOGRAPHIC / LAND SETTING (check appropriate box)
Slope 7, "alley j F lat r I Ridge ❑Other
LATITUDE 36 ___ DMS OR 3x XXXXXXXX DD
DMS OR 7x XXXXXXXX DD
AM❑
PMi/
COUNTY
LONGITUDE 75
Latitude/longitude source �GPS OTopo9ra phrc map
Oocauon or .veil must oe moil on a USGS topo map andattached to
nis corm it not using GPS)
5 WELL
0
a
b
c
d
e YIELD (gprn)
f
Own€ r 9ame
Street Address
City or Town
rea cooe Phone number
WELL DETAILS
TOTAL DEPTH
�r✓s
State Zip Code
DOES WELL REPLACE EXISTING WELL? YES
WATER LEVEL Below Top of Casing _FT
(Use - if AbovefTop of Casing)
TOP OF CASING IS _!-- FT Above Land Surface
l op or casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C 0118
OF TEST sir%
DISINFECTION Type Amount
NO
Top Bottom
Top Bottom
8 GROUT Deptn lop d Borrom 2,67
Top Bottom
Top Bottom
Material
Ft C'®G' G-rC(
Ft
Ft
Metnoe
r✓o '4 K-0
9 SCREEN Depth
Diameter Slot Size Material
Top Bottom Ft In rn
fop Bottomin Ft -
lop
Bottom Fr in in
10 SAND/GRAVEL PACK
Depth
Top Bottom Ft
Top Bottom Ft
Top
Bottom_ Ft
11 DRILLING LOG
Top Bottom
c' / 3c
3D / 40
66 /70
-7 6 / _7 _
,2 REMARKS
Size Material
Formation Description
6a9L
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUC r2D
ACCORDANCE WITH 15A NCAC 2C WELL CONSTRUC i )Or
STA •-'DS AND THAT A COPY OF THIS RECORD HAS BEET.
P-•VIDE 1 TO THE WELL OWNER
CONTRACTOR
DATE
PRINTED NAME •F P-''SON CONSTRUCTING THE WELL
Form 3A' r
Rev 2/09
Submit within 30 days of completion to Division of Water Quality -
1617 Mall Service Center, Raleigh, NC 27699-161, Phone [phone]
Information Processing