383835_Well Construction - GW1_20100428

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WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources
- Division of Water Quality - Groundwater Section/
WELL CONTRACTOR (INDIVIDUAL) NAME (print) E�,wcJeti v �7'•CERTIFICATION�#0/° /
WELL CONTRACTOR COMPANY NAME CcL-�u 4.!--vv, a-/ I jam, rl i K PHONE W(d 412" 64
7
STATE WELL CONSTRUCTION PERMIT# O I O - SU / ASSOCIATED WQ PERMIT#ON- L,O1vJ. 6 9 -/�9
(if applicable) (if applicable)
_
1. WELL USE (Check Applicable Box): Residential 0 Municipal/Public Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION //
Nearest Town• oil,/b'.' Countyv� h / 6 A'
26" / O/d /7��,la,1d /4 ort, v- ,ed
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: F/� %�>'c-+� t .+. C 14
Address 24/ O/d. Poe-1.--J' » v'e fe4,
AnA (Street or Route No.)
On✓tse., .UC ZT// Z
City or Town State Zip Code
'7O`1')-22.--/a7(•
Area code- Phone number
4. DATE DRILLED — //
5. TOTAL DEPTH: 3 6 5
6. DOES WELL REPLACE EXISTING WELL? YE CIO ❑
7. STATIC WATER LEVEL Below Top of Casing: 3 G 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): ZO METHOD OF TEST A'r
10. WATER ZONES (depth): ` — / $ G pm
-S GF'�
11. DISINFECTION: Type N T// Amount V O Z .
12. CASING:
Wall Thickness
Depth i4imeter or Weight/Ft. Material
From — / To ,�?i Ft. re D.- 7i/ f t/G
303S35
Topoggr phic/Land setting
❑Ridge O'S-tope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To , or on Dcrti
Ye-/haatiw Wesipon
a / .
41 / 7' 5411- arowh /4—te,
/ g.' 3 a.i ' ?/w t 57c 1e
LOCATION SKETCH
Show direction and distance in miles from at (east
two State Roads or County Roads. Include the road
numbers and common road names
RECEIVED
10(282010
Unit
G ; ormation Processing
DWOBOG
16. REMARKS:
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 5-1 Ft. 'e rt:1.4h t�C, /21^-s"r
From To Ft.
14. SCREEN: Depth Diameter Slot Size
From _ To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTISTANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
dd 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