385373_Well Construction - GW1_20100712

RESIDENTIAL
335S3
RESIDENTIAL WELL CONSTRUCTION RECORD 3 5373
North Carolina Department of Environment and Natural Resources. Division of WaRlityF
WELL CONTRACTOR CERTIFICATION # 1 S .) l) I 2 6 2012
1. WELL CONTRACTOR:
Only e1k-u/L-S
WeA ontractor (Ind anie
c4 (ual) v,��
Well Contractor Company Name STFiE ADORES ()^�U/1,� \ �V 'ic) k sk •
, City o Town State
itti Qo -i SO
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID *of applicable)
STATE WELL PERMFF#(if applicable) i ()C,(y
DWQ or OTHER PERMIT *Of applicable)
WELL USE (Check Applicable Box): Residential Water Supply p
DATE DRILLED
TIME COMPLETED AM PM 0
3. WELL LOCATION:. 721tC7(C({'l{ al I
CITY: COUNTY lJI'JC)d'L
Zip Code
(Street Name, Numbers, Community, SubdMeion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE -•_ ..S, S I ID -
LONGITUDE I _O '1)CS . L'Lia.
Latitude/longitude source: eI PS ❑Topographic map
(Iocatlon of wad must be shown on a USGS topo map and
attached to this form rfnot using GPS)
4. WELL OWNER
OWNER'S NAME I f / (COL S Cki'E{i�jCrl a(rru2i
D STR ADDRESS 1) 1 ('r� Ll i ( t. (5 reVArti
l r.
6� I,101tak -'kc4 T ,1i,%i • D(Yj
City or Town State Zip Code
q 1 *)
May be in degrees,
minutes, seconds or
in a decimal format
Area code • Phone number
5. WELL DETAILS: '� )
a. TOTAL DEPTH: �?'v
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: 70 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING (3 I/FT. Above Land Surface
`Top of casing terminated atfor below land surface may require
a variance In accordance with 15A NCAC 2C .011 .
e. YIELD (gpm): I 00 METHOD OF TEST �le `�✓
f. DISINFECTION: Type (4
g. WATERZONES (depth: to c
//
From —1 v To From
From To
From To
8. CASING:
From �' I DTepoth"-ICI Ft. Di(:%Lf
From To FL
From To Ft.
Amount I (' u
if
From
From
To
To
To
Thickness/
We,.. Mat al
7. GROUT: Depth mMaterial /
Fro_ To3� Ft. po r'-ICI v
From To Ft�
From To Ft`-.
B. SCREEN: Depth Diameter Slot Size
From To Ft. In. In.
From To Ft. In. In.
From To Ft: In. in.
8. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
From To. Ft.
10. DRILLING LOG
From. To
—
.1 12L-
3 OO
11. REMARKS:
Material
Material
Forrrliation �Descriptlo ^ii-ei i' r✓I-+C��/)i1Ir' ,
J
m � "-No— t R f ff7:
1111 1 2 Z
Information procassing Unit
DWQ/BOG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
16A Nev., 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WEU.OWNER.
SI TURE OF CERTIFIED WELL CONTRACTOR
CM/ (.J / r-6/1c
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
V
DATE
reiC%
Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt.,
1617 Mall Service Center— Raleigh, NC 27699-1817 Phone No. [phone] eat 668.
Form GWl a
Rev. 7/05

-S3S3
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 1 S
1. WELLCONTRACTQR:
WeM ontractor (Individual) erne
e C- t 1
Weil Contractor Company Name `
SIRE ADORES (c 1 V/1im% icy Ski v-
C� k)(
City o Town State Zip Code
(lt)L()- CQL `( SCE
Area coda- Phone number
2. WELL INFORMATION:
SITE WELL ID 9(if epplicable)
STATE WELL PERMITVapplicable) 1 CAy
DWQ or OTHER PERMIT #(If applicable)
WELL USE (CheckAppflcable Box): Residential Water Supply El
DATE DRILLED
TIME COMPLETED AM 0 PM 0
3.WELL LOCATION: .:: jC(ik Gil
CITY: C COUNTY L...1311C)4L
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC 1 LAND SETTING:
❑Slope'DValley:OFlat DRidge ❑Other
(check appro ate box)
LATITUDE .:,. C) 11.
LONGITUDE1'j 5 . ()LI
Latitude/longitude source: ¢'OPS °Topographic map
(location of well must be shown on USGS topo map and
attached tothisfwm if not using GPS)
4. WELL OWNER -
OWNER'S NAME V + 1 ICO. S
May be in degrees,
minutes, seconds or
in a decimal format
STR • ADDRESS t n
col 1viol f (IX eu 4 ! x,
ZIp Code
City or Tawn Stetec)_Li
Area code • Phone number
8. WELL DETAILS: �e
a. TOTAL DEPTH: �'
b. DOES WELL-REPLAGEEHST1NGWEi-t?- ES EI---NG V
c. WATER LEVEL Below Top of Casing: X) FT.
(Use "f" If Above Top of Casing)
d. TOP OF CASINO IS If FT. Above Land Surface
*Top of casing terminated atlor below land surface may require
a variance In accordance with 15A NCAC 2C ,011 .,
e. YIELD (gpm): ) 0 0 METHOD OF TEST i 11(..1
/1411P)
3 6, 5 61
L DISINFECTION: Type (•4 t (+ Amount Le
g. WATER ZONES (depth]: C
From 7 (.) To ( l From To
From To
From To
From To
From To_,__
8. CASING: Thickness/
Depth. Dlametpr We...
From .r ( To WA Ft. (n /=i
From To Ft.
From To Ft.
7. GROUT: Depth //�Mated
From 0 -TO-)q Ft.
From To Ft,
From To Ft
C
Method
dii(IJ
8. SCREEN: Depth Diameter Stot SILO Material
From To Ft. In. In.
From To Ft. In. In.
Fr To�y.� F,t • in. In.
8. SNDIGRAVEL PACK
Depth Size Majprial
From 1' t VC -
To (o 0 Ft.
o Ft.
From • To Ft.
-,moo 1- 0 o CcU
From T
10. DRILLING LOG
From To
0 —1.1
3) -.cc
11. REMARKS:
Fo tion Descriptio
; "
%a el
t^�? t' ec.s repel- /'
•
pizza. PPM\
( A -Ivt=.0
SEP 1 — ?nln
infnrmatinn Prnraccinn I 'nit
nyvnIRnr;
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
1SA NC5G WEU. NS UCTION STANDARDS, AND 1HAT A COPY OF THIS
REGOttD S2GBEENPj101A DTOTHE WELL OWNER.
rlJ
( i ..4,. - —(o
SIGNATURE OF ERTJEIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attu: information Mgt,
1617 Mall Service Center— Raleigh, NC 27699-1617 Phone No. (919) 7334016 eat 668.
Form GW1a
Rev. 7/05