383889_Well Construction - GW1_20100526

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 1
1. WELLI NTRACTOR:
t J0u t 6 Stria-o r3S
Well C actor Ind uai) Na
o caL l)rod S
Well Contractor Company Name 1 /� r �
STREET ADDRESS (� 1 1 O kk, h e
G e. , (
City or Tow State
Lc 3CCt-156Co
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(rfapplicable) %C6 C) t( 5Ct
DWQ or OTHER PERMIT Cif applicable)
WELL USE (Check Applicable Box): Residential Water Supply o
DATE DRILLED
TIME COMPLETED AM ❑ PM 0
Zip Code
3. WELL LOCATION: .) r I
CITY: l/V1c ` COUNTY i l eClc(P%tIei
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
eiSiope ❑Vsltey CIFlat ❑Ridge oOther
(check appropriate box)
LATITUDE J,,
LONGITUDE J„
5
May ba in degrees,
minutes, seconds or
in a decimal fomtat
Latitude/longitude source: oGPS °Topographic map
(location of well must be shown on a USGS topo map and
attached to this form !Mot using GPS)
4. WELL OWNER /� QOWNER'S NAME 0 0,STREET A9DS 1 Lp a.1(P �— i It U (k(WC)(
�✓o e AIP
City or Town State
( 70111)- `CP° tl 416
Area code . Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 0
Zip Code
b. DOES WELL REPLACE EXISTING WELL? Yl; NO 0
c. WATER LEVEL Below Top of Casing: FT.
(Use "f" If Above Top of Casing)
d. TOP OF CASING 1S i V'L FT. Above Land Surface*
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): L METHOD OF TEST /VD LA-3
3 3 , d
a
f. DISINFECTION: Type %'t-
Amount / Z CtJY7
g. WATER ZONES (depth): d%
From 1 cod. To ( 0 I 1/From
From To
From _To
6. CASING:
Depth
From__ To 1 )L-\ Ft.,
From To FL
From To Ft.
To
From To
From To
Thlcknessl
Diameter Wrlyes
7. GROUT: Depth Materlai
/ Method
From () Tod-d_ Ft. h e AA-;1,-. -I .e
From To Ft,
From To Ft`
8. SCREEN: Depth Diameter Stot Size Material
From To Ft. In. In.
From To Ft ' In. In.
From To Ft. In. In
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From a
-10
GO —aLL(O
11. REMARKS:
Formatio Description
r) G
100
15A
RE
SIG
EBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
C 2C, WELL • NSTR • • STANDARDS, AND THAT A COPY OF THIS
HAS BEENP:OVIDEO THE WM .OWNER.
RE OF CERTIFI
t
D WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt.,
1617 Mall Service Center— Raleigh, NC 27699-1617 Phone No. [phone] eat 668.
Form GW1a
Rev. 7/05