390563_Well Construction - GW1_20110107

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # (r)
1. WEIA, CONTRACTOR:
IYWV
Well Contractor
(IInddMdual) (Name ( I
l Contractor Company Name 6e 1 1f1 \ t'AL5
Wei
STR ET ADDRESS0 K 4.� Ai r'C x
CiAcu-k NCagaai
ity or�wn Sta a ct Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) 1 C 33'
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE GRILLED I - 1 cI a
TIME COMPLETED 5'1 CS:), AM ❑ PIA
3. WELL LOCATION:
/y
CITY: / /O/V it ®a
COUNTY
(43a\ er Vtil
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAN TTING:
0 Slope ❑ Valley . lat ❑ Ridge
(check appropriate box)
LATITUDE 3
LONGITUDE "
0
Latitude/longitude source:
❑ Other
May be in degrees,
minutes, seconds or
• in a decimal format
per< ❑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
OWNER'S NAME `I'1C.-t 41c_c" Gi r`(vts
STREET ADDRESS `-t ✓o& ` Vl6CV) S`
City or
)- � o�— Tcwn f tate(p CD 7 Zip Code
-rJO
Area code - Phone number
5. WELL DETAILS: ��
a. TOTAL DEPTH: /
b. DOES WELL REPLACE EXISTING WELL? YES 6 NO ❑
c. WATER LEVEL Below Top of Casing: y� 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.
(� n
e. YIELD (gpm): A- METHOD OF TEST ! ' ! /1
f. DISINFECTION: Type /-T ! J4
g. WATER ZONES (depth):
From 3-56 To 76° From To
From 4/.36 To fir%/SO From To
FromS� 0 To 7 60 From To
6. CASING: �7 Thickness/
D Depth
y/ Ft. Coagyeter Wej O ��tgrj�li
Fromr //t (�
From To Ft.
From To Ft.
Amount /-% i /0-
7. GROUT: Depth P Materialv%iaMethod/
From 6 To 35 Ft. Rei/t , e •P(//�Pe
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
From
From
From
Size Material
To Ft.
To Ft.
To Ft.
10. pRILLING LOG
FroDmt T:10•
,3o ', « 1
419/66'
/hb ,ao'
,/bo ' ,366
3uo S'
11. REMARKS:
__ER/ED
0/2011
Ihr�rrr: ; 1 i •,,,r.ess
O11'KQ/BOn Unit
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRI ICTED IN ACCORDANCF WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
rr►, / L & i // AA-/6
SIGN RE OF CERTIFIED WELL CONTRACTOR DATE
0-61)ry PI, r-)caa'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