386264_Well Construction - GW1_20100813

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7 366254
From
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resourcesur- Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAMES �(print) El*Se,w�,- eeli . CERTIFICATION 2J 1
WELL CONTRACTOR COMPANY NAME co..,LL /G
afn%1 De'i1: AI PHONE #74'�Gw 3-T-66 7
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#M t db Cat .I..�j / 0 ,r6
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIO
•
Nearest Town: "eve-. County 1/Ci /*/'
W til r6"Pc r .2.07t.#J
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: %/+Set,, 7' C4- elr. %+� 6tssr.
Address /31-7 ble1w.s Sky Y� L IAA (l' •
(Street or Route No.)
/Mu nrog- AJC 1-2112.
City or Town State Zip Code
PVC,-Zal -31r? •
Area code- Phone number
4. DATE DRILLED 7- / / - "
5. TOTAL DEPTH: /'j1
6. DOES WELL REPLACE EXISTING WELL? YES 0 >04%
7. STATIC WATER LEVEL Below Top of Casing: 3 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm):. / 6 METHOD OF TEST /49/ r
10. WATER ZONES (depth): Z -' ' GPr7
f' -CGPri
11. DISINFECTION: Type / / 7W
12. CASING:
Depth 99tameter
From / To tie 6 Ft.Carit
From To Ft.
From To Ft.
Amount 4_ a Z..
Wall Thickness
or Weight/Ft. Material
AR -VI PVC
13. GROUT: Depth Materials
From To .3s Ft.
From To Ft.
Method
P�+�p
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. ' in. in.
To Ft. in. in.
Topographic/Land setting
DRidge Sio-pe ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
Fro0m %i �omation Description
c.
/ Z'
,3
/
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
REC N ED
1
d lJe. tt pU G TA
ANIFICO
r cessin9 Unit
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
% zd -/ o
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001