384430_Well Construction - GW1_20100610

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
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WELL CONTRACTOR CERTIFICATION # � (13 6)e30
1. WELL CONTRACTOR:
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Well Contractor (Individual),Name
elContractor mpany,J;Vame
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treet Address � � a iaari
City or Town State Zip Code
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# ` V — 35
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box). Residential Water Supply itr-
DATE DRILLED / a 3 - l o
TIME COMPLETED' L%A 0 AM ❑ PM r-
4. WELL LOCATION:
CITY rl VIU/D e COUNTY WAX ON
AP5 T-red
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING' (check appropnate box)
❑Slope ❑Valley fat ❑ Ridge ❑Other
LATITUDE as 3Cl \$ 0 6 3 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE o o.3g' / 9 (0 "DMS OR 7X300000000( DD
Latitude/longitude source topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
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eers
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Address (� \
City pr Town _ State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: auk)
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO LV"
c. WATER LEVEL Below Top of Casing c2. FT
(Use "+" rf 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
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e. YIELD (gpm). / 6 METHOD OF TEST % iK
f. DISINFECTION: Type c=k Amount AL S
s I/ tr'
g. wATER ZONES (epth) n
Top S Bottom I iib u Top 1� Bottom
Top ) /5 Bottom / oO Top Bottom
Top / Jf r'
Bottom / y 7 Top Bottom
Thickness/
Weight Material
7. CASING: Depth Diameter
Top 0 Bottom 9 / Ft 14?
Top Bottom Ft
Top Bottom Ft
8 GROUT: Depth Material
Top 0 Bottom 35 Ft i5C4)76/lae
Top Bottom , Ft.
Top Bottom Ft
9. SCREEN: Depth Diameter Slot Size Material
Top Bottom Ft in. in
Top Bottom Ft in. in
Top Bottom Ft in. in
Method
perpred
10. SAND/GRAVEL PACK:
Depth
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
7v / 8a'
Kb I/DO
/[aa / ACO J
12 REMARKS
Size Material
F rrnPabpn Descnption
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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
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SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
J6 A ru r i . My 44 :5
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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