390566_Well Construction - GW1_20110107

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 1::2v -33
1. WELL CONTRACTOR:
1 n1nr\
Well Contractor (Individual) Name
--Nu Mu t ,` s U�ei �h l i I(�g
Well Contractor Company Name
BEET ADDRESSCI a 00 16, 0-- t I Pel
' rN-- a
City or Town State Zip Code
( Oyi � Ll (n 4U
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)
10--30
DWQ or OTHER PERMIT #(if applicable)
TIME COMPLETED
3. WELL LOCATION:
CITY: (;f3 t cR1/4S'-011 COUNTY n lr CY )
1(p 16 ckw-ci,; i i 2», Dv
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑Valley at ❑ Ridge ❑ Other
(check appropriate box)
LATITUDE 3 L� o 59. (D /g' /
LONGITUDE y%. C1 -!
a
Latitude/longitudee_ssoource: p.P'Ifi S ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED rl �� V rn
03 AM ❑ PM
May be in degrees,
minutes, seconds or
• in a decimal format
4. WELL OWNER ,, �`� ��
OWNER'S NAME ,.1 eSYv\ fl_d ' 1
STR ET ADDRESS I . `] Cf `tJ✓C :� Ili 1I
WO, \ c__ n 3
City or Town State Zip Code
kl a 2 c 3
Area code - Phone noffnber
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL?
2,?YESS ID NO,
c. WATER LEVEL Below Top of Casing: Jv 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. 1\
e. YIELD (gpm): I / METHOD OF TEST t f
3 0 ,�
56
f. DISINFECTION: Type 4 1-IAmount pi-
g. WATER ZONES (depth):
From 'b o To Ir) b From To
FromU'1S To LA CC b From To
Froml \ q 5 To q 9 From To
6. CASING: Thickness/
" Depth 9lsij ,er Weight M griial
From V To i 0t Ft. (� lei
`� I' v e
/X i Ili,
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From 0 To an Ft. Rcet ft -i-e-.
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 0 To 00 Ft. 1-1 It PC_- I; IN C r 4-'
From To Ft. Li 1C. (D p Q CC-P r
From To Ft.
10. DRILLING LOG
From To Formation Description
L1 t --' 9 0' a- hv0.. +.,-\ �0_ citc-
9 o ' - R c7` -hyn e, (3irrAn k %e-
oi 0' - CCU' Sri-' rI i-k l -- ---
I ool -- l a w -,ri Act nt-k_ t e- vj4C.; i--ems
Q C\ - pQ f 7 it l 1.-iti-AN A +. i,1 e.—
a.�.�-uo' Yj(�.. IritN.N_\
uk 1st ^SOo` .J _ ,r, i }e...
JAN 7
0 2011
11. REMARKS: Information Processing Unit
DWQ/BOG
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGN U E OF CERTIFIED WELL CONTRACTOR DATE
c nSO uit t s
PRINTED NAME OF PERCONSTRUCTING 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