390564_Well Construction - GW1_20110107

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2 6 3 W
1. WELL C � R,
it � i, 1 k 1
Well Contracto Individual) Name
rt
Well Contractor Company Name
STREET ADDRESS r�- S T Frt C- 1 t 1 I 1
J n r 1 (l-- i%Vc_ Sa. d ri
City or Town State Zip Code
9 1-!
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable) 10 " aoo
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED 1 a -I O
TIME COMPLETED 5 (.33 AM 0 PM7
3. WELL LOCATION: (
CITY: iIV)Cv Sp��3S COUNTY -KrA1 n
l \\ R\-.z VoA-V-
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LA ETTING:
❑ Slope ❑ Valley Flat 0 Ridge 0 Other
(check appropriate box)
LATITUDES );) (p k g5/?ry
LONGITUDE lS O `- 0� r 6 t(� /
Latitude/longitude source: $iBS ❑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
OWNER'S NAMEC)
STREET ADDRESS CP o' - L_ e S i r\
har \ - _ 9ai C�
State Zip Code
May be in degrees,
minutes, seconds or
• in a decimal format
City or TovAL
QW_- Cif, daa
Area code - Phone number
5. WELL DETAILS: n r
a. TOTAL DEPTH: alb a
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO IJ
r
c. WATER LEVEL Below Top of Casing: c S6 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): 66 METHOD OF TEST AR
f. DISINFECTION: Type / r %i 9
g. WATERR ZONES (depth):
/
From ,S76 To / 0 D
From To
From To
6. CASING:
Depthh 4 Diameter
From d To I6 Ft. (p VP
From To Ft:
From To Ft.
7. GROUT: Depth Material Method
Amount 2 .., i /U/S
From To
From To
From To
Thickness/
From rC5 To ,35 Ft. /7 eiv/o/b./tA
From To Ft,
From To Ft.
8. SCREEN:
From
Depth Diameter Slot Size
Ft. in.
From To Ft. in.
From To Ft. in.
9. SAND/GRAVEL PACK:
Depth
From
From
From
in.
in.
in.
Material
Size Material
To Ft.
To Ft.
To Ft.
10. pRILLING LOG
Frorp fi
11. REMARKS:
Fo atio D ri tio/n
fi 6cf ��qSA 4t e
MJb
Lie S41 A.,
47
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRI ICTED IN ACCORDANCF Wm-1
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
j' r�r''
SIGNAT OF CERTIFIED WELL CONTRACTOR DATE
(.0)1rU m, r igh43
PRINTED NAME OF PERSON CONSTRUCTING THE WEL
RECEIVED
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., F, 1 GW-la
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568. { J U 7 24 J, 7/05
ifrorrfl tion processing Unit
DWQ/BOG