394098_Well Construction - GW1_20110513

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 0 3 g
1. WELL C
ell Contractor Company Name
STREET ADDRESS
ity or Town Staten � Zip Code
'Area code- hone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable) / 6 / / 3 3
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check ApplicableJJBox): Residential Water Supply f
DATE'DRILLED S—%f' -1 /
TIME COMPLETED Jo? "60 AM EPM ❑
3. WELL LOCATION: /�y�
CITY: /yy1 OfU O COUNTY 617t/r,C/h
V
tcs b'r'T Rd D)
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
��
❑Slope ❑Valley Ii!fFlat 0Ridge ❑Other
(check appropriate box)
LATITUDE 3 y ,J .. 15
/6 j p
LONGITUDE 2( 3'/ / AO
Latitude/longitude source: BPS oTopographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER ,/ & !
OWNER'S NAME / ) e e l(p ` n ,�jf,J s
STREET ADDRESS /,q,,30 Re /',4.'ec77 vs I.7,
r'1 r 4 e %U. C 2f//L
City or Town State Zip Code
( 96'/ )• A�� b5o E
May be in degrees,
minutes, seconds or
• in a decimal format
Area code - Phone number
5. WELL DETAILS: � A O I
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO LT
c. WATER LEVEL Below Top of Casing: 3S , FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS / 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): /2 METHOD OF TEST el R
3 c 4 0 9 8
f. DISINFECTION: Type /7914 Amount / it
,j
g. WATER ZONES (depth):
From / 65 To // 5 From To •
_.
From /3 S To / 9( From To
From To From To
6. CASING: !� Thickness/�
From DTothS, Ft. CO-er W/. M/:Vae
From To Ft.
From To Ft.
7. GROUT: Depth r � Material�Method
-/
From 0 To 3Ft. �P/l%/a/L, /�
I2y
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.
From To Ft.
From To Ft.
10. DRILLING LOG
From To 1 Fo ation Des pion
'{d 2 '
LZ'Own) 4 -
O I/?owrv, ;
5'. 9.�'' 4ii i�-
d G '� A2 -
ii 1a
56 - t f , e
,5',iv
Y
11. REMARKS: Mp,`( 1. 3 2011
. t !nit
tntormati6n,tot;.,;
..��IaC�GG ,
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 WEOWNER.
��
l -�G 4 j'" 7�/
/ 7) ' s�- —/tl
SIGNAT �OF CERTIFIED WELL CONTRACTOR DATE
4,3
PRINTED NAME OF PERSON,CONSTRUCTING HE WELL
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] ext 568.
Form GW-la
Rev. 7/05