384429_Well Construction - GW1_20100610

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quali1 u Q
WELL CONTRACTOR CERTIFICATION #
1. WELL COIJRACTOR:
C),\A �� (1 LA ►1 t Kt-mi t vce 1 14-
Well Contractor (Indivrdual),Name
b L (Y\ 1 � S e I N Yl r nlq
► r -11 Contractor Co i pany N e .J
t Address
City or Town']' _ r �—,
(1Areh(he *) 9 L1
2. WELL INFORMATION: WELL CONSTRUCTION PERMIT# OF- 39
2
State Zip Code
OTHER ASSOCIATED PERMIT#(rf applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box) Residential Water Supply ❑
DATE DRILLED y !'g A 7/ti/V
TIME COMPLETED' Co , v 6 AM ❑ PM
4. WELL LOCATIIO
CITY: w PGAQ/ /15..1art) COUNTY UN, Q /v
, l.� GGt-c7 -Pi— 5 I lo
(Street Name, bars, Community, Subdivision, Lot No , Parcel, Zip Code)
OPOGRAPHIC / LAND SETTING- (check appropnate box)
to e, ❑ Valley ❑ Flat 0 RidgeID Other
LATITUDE ti/39 "31' 0p " DMS OR 3X.X00C0000EX DD
LONGITUDE a SO *3 9 " DMS OR 7X.XXXXXXX)0C DD
Latitude/longitude source
(location of well must be sh
this form if not using GPS)
Owner Name
�i M
S Dropographic map
n on a USGS topo map andattached to
03`j °
LI'1_
t.rvet Address
NC . C473
City or Town cl State Zip Code
L �., 1//
Area codeCDCho a number'
6. WELL DETAILS: /ry +�
a. TOTAL DEPTH: 3 (0� r
b. DOES WELL REPLACE EXISTING WELL? Y-ESC❑ NO I
c. WATER LEVEL Below Top of Casing du FT
(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) O b METHOD OF TEST gig
f. DISINFECTION: Type Amount 02/1417$
2O 3PI:203c,
g. WATER ZONES (depth):
Top %S Bottom /d 0 Top Bottom
Top35-5 Bottom 3(06 Top Bottom
Top Bottom Top Bottom
Thickness)
7. CASING: Depth Diameter Weight
Top 0 Bottom.5 Ft 6 /? r ids
Top Bottom Ft
Top Bottom Ft
8. GROUT. Depth z
Top 0 Bottom 3 J-
Ft
Top Bottom Ft
Top Bottom Ft
9. SCREEN: Depth
Matenal
e`i 4oiu;te
Material
pv.c
Method
Diameter Slot Size Material
Top Bottom Ft in
Top Bottom Ft in
Top Bottom Ft in.
in
in.
in
10. SAND/GRAVEL PACK:
Depth Size Material
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11. DRILLING LOG
To Bottom F ati n D cnption
0 / as , Neal c Ai4y
AO / �ow� SAle
3S / !/e, ,SL /17"i-
rjA / /06' e ,524te
/OO / AO • 3.9 e
l 3(S' ,3/7 /77 e
12. REMARKS
ELC
-.iv 14 201Q
Inforrri t -,
-
DY✓e"
Q/qt u� U+1ft
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
SIGNA RE OF CERTIFIED WELL CONTRACTOR DATE
ON & P J. /'') u&, h ; S
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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