394114_Well Construction - GW1_20110513

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 6357
1. WELL CONTRACTOR:
011 im U 114s
Well Contractor (Individual) Name
(•fflui1V-s l.U3e1) \VA5
Well Contractor Company Name J
STREET ADDRESS t t 1
\1i1:���-�e. ►N\C, ai o�a1
JZip Code
Area code- Phone number ll�
2. WELL INFORMATION:
SITE WELL ID #(if applicable) /
STATE WELL PERMIT#(it applicable) 1L " l b
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply E
DATE DRILLED / A 5 -/ / /
TIME COMPLETED 7,�G AM ❑ Ly PM s
3. WELL LOCATION: `efyet CITY: i�ON 11 COUNTY ,,D/V
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zia Code)
TOPOGRAPHIC /1,.A90 SETTING:
❑ Slope ❑ Valley*flat ❑ Ridge ❑ Other
(check appropriate box) LATITUDE 3 5° O 3(,
LONGITUDE / a(p,`Julp
Latitude/longitude source: lbfi`'iPS DI Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER l i c
OWNER'S NAME Uji .S '1 e c� / m o SO%v
STREET ADDRESS ,3yo y Gieee/ue Rd
May be in degrees,
minutes, seconds or
in a decimal format
f') orvRV e tic f//0,
City or Town State
(104_J-.163-1 NACI
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 91 6G
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES j NO ❑
c. WATER LEVEL Below Top of Casing:
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS
25 FT.
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): A 6 METHOD OF TEST
3
f. DISINFECTION: Type T'tl Amount /"p Iv /
g. WATERZONES(depth)
/ J:
From To / 0 5 From To
From / y J To /5° From To
From / %X To / 7.5 From To
6. CASING:
From ©DTottSScS Ft. h D}arrj�1r
From To Ft. GP
From To Ft.
Thickness/
Weight_ flgaje;rii
7. GROUT: Depth , Material
0 To 35 Ft. Betti/f Grp
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
Fr n1 To
0
G'
1,16 A6
11. REMARKS:
0
atio
Desc lotion
rK ma
MAY 13 2011
Information Proc.J:s no Unit
L)WQ/BOG
1 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 WELL OWNER.
1-; 7-
))
SIGP4jrTURE OF CERTIFIED WELL CONTRACTOR DATE
c7-31,(,P?c,.2l�S
PRINTED NAME OF PERSON CONSTRUCTING THE 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