384413_Well Construction - GW1_20100610

❑ Slope
LATITUDE 36
LONGITUDE 75 * Y,l.r� r]�' DMS OR 7X.)00000 ,00r DD
Latitude/longitude source.: L PS QTopographic map
(location of well must be shown on a USGS tope map andattached to
this form if not using GPS)
5. WELL OWNER
er Name
---cut, L. Nr
Street Address
IfV1 k mu\ fi c. I `73
1. WELL C
RESIDENTIAL WELL CONSTRUCTION RECORD ' l oViC
- North Carolina Department of Environment and Natural Resources- Division of Water
.Qaaliy 4 4.3
WELL CONTRACTOR CERTIFICATION #
Well Contractor (Individual) Name S
I Contractor Company Name
Street Address
City or Tovnu
A a code one number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
8.Dar-7.
State Zip Code
3. WELL USE (Check Applicable Box): Residential Water Supply p�
DATE DRILLED / / / / Q
TIME COMPLETED: 5 i aJ AM 0 PM [3(
4. WELL LOCATION:
CITY: G(COUNTY
o3 b►el-X�� )V .
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIE / LAND SETTING: (check appropriate box)
✓/alley p Flat p Ridge ❑ Other
f
57, s "DMS OR 3X.)00000o0CX DD
Urn
City or Town
State Zip Code
Area code Phone number
6: WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES p NO
c. WATER LEVEL Below Top of Casing: 0
(Use "+^ if Above Top of Casing)
d. TOP OF CASING 1S I 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): 9 METHOD OF. TEST t1 r
f. DISINFECTION: Type (-VT /-4 Amount
FT.
g. WATER ZONES (depth): •
Tope_ Bottom Top
Top3_ Bottom L X Top
"Top I oLo 5 Bottom (D 15 Top
Bottom
Bottom
Bottom
Depth Thickness/
7. CASING: De
p Diameter Weight
Top_a_ Bottom J Ft.c ' .h6)%
Top Bottom Ft.
Top Bottom FL
8. GROUT: Depth Material
Top 0 Bottom c2 0 Ft:: _ :n ti -
Top Bottom FL
Top Bottom Ft:
9. SCREEN: Depth
Top Bottom FL
Top Bottom Ft.
Top Bottom Ft.
10. SAND/GRAVEL PACK:
Depth
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 / I`D
3Uo / LICX-\`
u 03 I Ca c3O
(0 00 I (p 7 t
(i9(70I4-1-
/
/
/
./
/
12. REMARKS:
Material
Method
Diameter Slot Size Material
in.
in.
in..
in.
in.
in.
Size Material
Formation Description
d- a 1,c S h C-
Uli
•
n:n
yp LU iU
.. f�rnC,F,sso 9, Unit
nvvQ/EOG
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.
^.
DATE
PRINTEDPEOIONSTRUCTING THE WELL
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