385372_Well Construction - GW1_20100612

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RESIDENTIAL WELL CONSTRUCTION RECORD2
North Carolina Department of Environment and Natural Resources- Division of Water Quality 3 a e j 2
WELL CONTRACTOR CERTIFICATION #
1. WE NTRACTOR:
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Weil Contracta indWe
ividual) 5i-tiht--ei S
Well Contractor Company Name
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STREET ADDRESS `VC) (.3YC) O V�E`ki
C.I fn A -LC
City or Town State
("Tills )- '��— ISC)
Cp zip coda
Area coda- Phone number
2. WELL INFORMATION:
SITE WELL ID At(if applicable)
STATE WELL PERMITB(if applIcabIeAr C6 k 0 S ,v t-kg--b 1�
DWQ or OTHER PERMIT Cif applicable) 0
WELL USE (Check Applicable Box): Residential Water Supply ❑ /
DATE DRILLED (0 � — lU
TIME COMPLETED AM 0 PM 0
3. WELL LOCATION:
CITY: U) (T(� COUNTY (: I I'�(nYN
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING;
❑Slope ['Valley ,I 1 Iat ❑Ridge ['Other
(check appropdate box)
LATITUDE ..31_ - , 5'a,., 5' 7
LONGITUDE cf 1. (. / 7
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: oGPS oTopographic map
(location of wefmust be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME ( Z- W _L 12 r0 tia- lei
STREET ADDRESS / *C) a% aro Imo/& L1J . J5 r tf
City or Town State Zip Code
Area code - Phone number
CIS e) P 4 J r-
8. WELL DETAILS:
a. TOTAL DEPTH: �LL�
b. DOES WELL REPLACE EXISTING WELL? YES
❑ NOk
e. WATER LEVEL Be(owTop of Casing: U FT.
(Use "f" if Above Top of Casing)
d. TOP OF CASING IS 1 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): METHOD OF TEST,
f. DISINFECTION: Type, + -1- Amount e.-L)195
g. WATER11( ZONES (depth):
3g i
From Y To c 11
From To
From To From To
From To From To
8. CASING:
Depth Diameter
From To Ft.
From To Ft.
From To Ft.
7. GROUT: Depth
Thickness/
Weight
Material
�M1 aterl Method
From_ To 3 S Ft. u U I C'tvAd --') a1• Q
From To Ft,
From To Ft,_
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. In. In.
From To Ft. In. In.
From To Ft. in. In.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft,
Front To Ft.
From To Ft.
10. DRILLING LOG
From To
b— t C'p
1I. REMARKS:
Formation Des 'ption
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�a re-9 >�
IIN.IC: t..,f'mv1I
JUL 1 2 2010
Inform&tine Farr„
DWQ/BOG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
18A NCAC$C, WELL CONSTRl STANDARDS, AND THAT A COPY OF THIS
RECOR WISBEEN P DED T THE WELL OWNER
STORE ��F2TIID WELL CONTRACTOR
jjjjjj CCU( )) /Pi v-olA
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] eat 588.
Form GW-la
Rev. 7/05